Total dietary regulation in the treatment of diabetes

MONOGRAPHS OF

THE ROCKEFELLER INSTITUTE

FOR MEDICAL RESEARCH

No. 11 October 15, 1919

TOTAL DIETARY REGULATION IN THE TREATMENT
OF DIABETES

By

FREDERICK M. ALLEN, M.D., EDGAR STILLMAN, M.D., and
REGINALD FITZ, M.D.

NEW YORK

The Rockefeller Institute for Medical Research

1919

LIBRARY

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ITHACA, N. Y.

3 1924 104 225 283

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Library

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http://www.archive.org/details/cu31924104225283

MONOGRAPH No. 11

TOTAL DIETARY REGULA'
TION IN THE TREATMENT
OF DIABETES.

BY

FREDERICK M. ALLEN, M.D., EDGAR STILLMAN, M.D., AND
REGINALD FITZ, M.D.

NEW YORK
The rockefeller institute for medical research

igi9

|<H^ '■4-4-L

PREFACE.

This monograph comprises the records of seventy-six out of one
hundred diabetic patients treated in the Hospital of The Rockefeller
Institute, and chapters on certain aspects of the clinical research.
The opening chapter was written as an introduction to the publication
as originally planned, and was to have been followed by chapters deal-
ing respectively with carbohydrate, protein, fat, total metabolism,
acidosis, pathology, etc., with combined animal and clinical experi-
ments, and a fairly complete survey of the hterature. Certain events,
however, have interfered with this program and publication is proceed-
ing in reverse order, the clinical part now appearing in advance of the
reports of the animal experiments. The latter will shortly appear in
a series of journal articles. Most of the collected bibliography, except
that pertaining to the history of the subject (Introduction) , has like-
wise been omitted from the present monograph. Reports by members
of the staff of this hospital, concerning chemical aspects of the dia-
betic problem or methods employed, are included in the bibUography
of Chapter I under the names of CuUen, Fitz, Pahner, Stilhnan, and
Van Slyke. The cooperation and courtesy received so liberally from
outside the Institute are acknowledged in the text as far as possible.

When publication is complete, it will be seen that the conclusions
rest upon a unified research composed of three principal interde-
pendent parts. One of these has compared clinical diabetes in its
principal characteristics with that produced experimentally in various
species of animals, and has shown that the latter, in the absence of
spontaneous tendencies, is influenced by changes in the total metab-
olism and body weight, and not by carbohydrate ingestion alone.
The second is the present chnical investigation, in which this principle
has been applied to patients. The third is a pathological study, not
yet finished, but included here in the form of a preliminary outline
because of its' important relation to the problems of treatment.

IV PREFACE

A therapeutic advance should mean a raising of the general level of
chnical results, in the sense of saving hfe in some proportion of cases
formerly fatal, and prolonging it to greater or less extent in the more
hopeless cases. Expectations of an actual cure, in the sense of a
restoration of the normal power of food assimilation, will necessarily
be disappointed in most cases under any dietetic treatment, and the
need of some more potent therapy than diet is a keen stimulus to
research. The method of treatment here presented has never been
proposed as such a cure, and ameHoration of the existing condition
and preservation of hfe and usefulness at the price of continued pre-
cautions have been recognized as the limit of present attainment in
diabetes. As set forth in the text, the mistakes incident to the
development of a new method have reduced the general results below
the theoretical ideal. The severity of the test is evident, however,
from the grave character of the cases chosen and their known fate
under former practice. The experience as a whole is believed to sus-
tain both the theoretical principle and its practical value for the
dietetic treatment of diabetes.

MONOGRAPH OP THE ROCKEFELLER INSTITUTE FOR MEDICAL RESEARCH,

NO. 11, October 15, 1919.

TOTAL DIETARY REGULATION IN THE TREATMENT OF

DIABETES.

By FREDERICK M. ALLEN, M.D., EDGAR STILLMAN, M.D., and REGINALD

FITZ, M.D.

{From the Hospital of The Rockefeller Institute for Medical Research.)
(Received for publication, April 29, 1918.)

CONTENTS.

Chapter I. Introduction. History 1

The Ancient Period (to 1675 A. D.) 2

The Second or Diagnostic Period (1675-1796) 8

The Period of Empiric Treatment (1796-1840-50) 14

The Modern or Experimental Period 21

Bibliography 65

Chapter II. General Plan of Treatment 79

General Measures 80

Routine Care of Patients 80

Ward Regulations and Clinical Remarks 82

Treatment up to Cessation of Glycosuria in Simple Cases 90

Emergencies and Complications 98

Acidosis 98

Infectious and Surgical Complications 115

Treatment following Cessation of Glycosuria 125

Ideals of Diet and Laboratory Control 137

Practical Management of Diets 148

Organization 148

Equipment 149

Special Features of Maintenance Diet 151

General Scheme and Specimen Diets 161

Food Tables 173

Chapter III. Case Records and Charts 177

Chapter IV. Pancreas Feeding 461

Chapter V. Exercise 468

Immediate Effect of Exercise on Blood Sugar 468

The Effect on Carbohydrate Tolerance and Glycosuria 488

The Use of Exercise in Various Classes of Patients 491

The More Permanent Effects of Exercise upon Assimilation and the
Diabetic Condition 495

V

VI CONTENTS

Chapter VI. The Influence of Fat in the Diet 500

Influence of Body Weight 501

Influence of Total Diet 502

Chapter VII. Results — Prognosis 532

Severity of Cases 532

Cases and Results by Decades 536

Causes of Death 557

Treatment of Coma 558

Infections 562

Reasons for Failure in Treatment 567

Severity of the Treatment 575

Prognosis 577

" Spontaneous Downward Progress" 581

General Summary 594

Chapter VIII. Etiology and Pathology 596

Etiology 596

Carbohydrate or Dietary Excess 596

Obesity 598

Pluriglandular Disorders 599

Constitutional Defects 600

Heredity. . . . : 600

Nervous Causes 605

Trauma 607

Infection and Inflammation 608

Pathology 615

Changes Causing Diabetes 615

Changes Due to Diabetes 620

Clinical Application 631

Chnical Etiology 631

Anatomic Diagnosis 636

Relation to Treatment 642

Conclusions 646

CHAPTER I.

INTRODUCTION.

History.

Understanding of the existing state of a subject is generally aided
by knowledge of its history. Aside from what is given in text-books,
notably those of Cantani and Lepine, the early history of diabetes has
been written briefly by Hirsch, but most exhaustively by Salomon, to
whom reference may be made for exact citations of most of the ancient
and medieval works here quoted. A previous publication^ has re-
viewed some of the theoretical and experimental features of the sub-
ject. The following account aims to trace the development of clinical
knowledge and treatment of diabetes, taking note of theories and ex-
periments only as they have influenced practice. The attempt has
been made to present the true and significant, assigning credit to the
successive workers as accurately as the recorded evidence permits.

It is convenient, following approximately Cantani, to divide the
history of diabetes into four periods. The first extends from the most
ancient times to the discovery of the sweetness of the urine by Willis
in 1675, which ushered in the second or diagnostic period. The third
period, that of empiric treatment, began with Rollo in 1796. The
fourth, or modern period, was inaugurated in the decade 1840 to 1850,
the most prominent founders being Bernard and Bouchardat. With
all its imperfections, this yet merits the name of the experimental
and scientific period.

»Men(l).

I. The Ancient Period (to 1675 A. D.).

"In the papyrus Ebers, which is a copy of an Egyptian medical
compilation already old in the time of Moses, there is mention of
polyuria, and it is hard to conceive that such a marked departure from
health could at any time have escaped observation" (Saundby). For
explanation of the relatively late period of human history at which
diabetes was first clearly recognized and described, we need not as-
sume the absence or rarity of the disease among the ancients, but must
rather consider the impossibility of their diagnosing mild cases, the
natural confusion of severe cases with chronic nephritis and various
forms of pol3mria and with tuberculosis and other wasting conditions,
and the further difl&culties presented by the various complications.
The differences between cases have puzzled even modern physicians
to such an extent that the existence of diabetes as a unified entity
rather than a disjointed symptom-complex has been disputed up to
very recent years.

Hippocrates (460-377 B.C.) made no mention of any condition
clearly recognizable as diabetes. A notion concerning the quantity of
urine, in a passage translated by Richardson from the third book of
the Epidemics,^ is like that of Celsus, but the first known recognition
of diabetes occurred at about the height of the Roman power.

Aulus Cornelius Celsus (30 B.C.-SO A.D.) wrote as follows:'
''When urine, even in excess of the drink, and flowing forth without

^ "In some cases the urine was not in proportion to the drink administered, but
greatly in excess ; and the badness of the urine was great, for it had not the proper
thickness nor concoction nor purged properly; for in many cases purgings by the
bladder indicated favorably, but in the greatest number they indicated a melting
of the body, disorder of the bowels, pain and a want of crisis."

'Lib. iv, cap. xx, 2; ref. by Salomon: "At cum urina super potionum modum
etiam sine dolore profluens maciem at periculum facit, si tenuis est, opus est
exercitatione et frictione, maximeque in sole, vel ad ignem; balneum rarum esse
debet, nequelonga in eo mora; cibus comprimens; vinum austerum meracvun, per
aestatem frigidum, per hiemem egelidum; sed tantum, quantum minimum sit.
Infima alvus quoque vel ducenda, vel lacte purgenda est. Si crassa urina est

2

HISTORY 3

pain, causes emaciation and danger, if it is thin, exercise and massage
are indicated, especially in the sun or before a fire; the bath should be
infrequent, nor should one linger long in it; the food should be con-
stipating, the wine sour and unmixed, in summer cold, in winter luke-
warm; but everything in smallest possible quantity. The bowels also
should be moved by enema, or purged with milk. If the urine is
thick, both exercise and massage should be more vigorous; one should
stay longer in the bath; the food should be light, the wine likewise.
In each disease, all things should be avoided that are accustomed to
increase urine."

In this compressed passage, Celsus gives the first description of
diabetes, introduces an error (fluid output greater than intake)
destined to endure eighteen centuries, and touches some modern treat-
ment. It is not known to what extent this knowledge was original
with Celsus or handed down by predecessors. At any rate, the recog-
nition of the disease was so new that it had not yet received a name.

Aretaeus of Cappadocia (30-90 A.D.), living under the emperor
Nero, and writing in Ionian Greek, was the second to describe dia-
betes, and the first known to have called it by the name {ha^alvav, to
run through; Sta/S^rijs, a siphon). In a passage translated by Schn6e*,

vehementior esse debet et exercitatio et frictio; longior in balneo mora; cibisopus
est tenuis; vinum idem. In utroque morbo vitanda omnia sunt, quae urinam
movere consuerunt."

^ "Diabetes is a strange disease, which fortunately is not very frequent. It con-
sists in the flesh and bones running together into urine. It is like dropsy in that
the cause of both is moisture and coldness, but in diabetes the moisture escapes
through the kidneys and bladder. The patients urinate unceasingly; the urine
keeps running like a rivulet. The Ulness develops very slowly. Its final outcome
is death. The emaciation increases very rapidly, so that the existence of the
patients is a sad and painful one. The patients are tortured by an unquenchable
thirst; they never cease drinking and urinating, and the quantity of the urine ex-
ceeds that of the liquid imbibed. Neither is there any use in trying to prevent the
patient froni urinating and from drinking; for if he abstains only a short time from
drinking his mouth becomes parched, and he feels as if a consximing fire were raging
in his bowels. The patient is tortured in a terrible manner by thirst. If he re-
tains the urine, the hips, loins, and testicles begin to swell; the swelling subsides as
soon as he passes the urine. When the illness begins, the mouth begins to be
parched, and the saliva is white and frothy. A sensation of heat and cold extends
down into the bladder as the illness progresses; and as it progresses still more there

4 CHAPTER I

Aretaeus outlines some of the principal symptoms, the progressive
course, and the fatal prognosis. He anticipates modem conceptions
of a failure of assimilation, conversion of tissue into urinary products,
and possible origin of some cases in acute infections. He was retro-
grade in treatment, for he advised a non-irritating diet of milk and
carbohydrates, andhiera, nardum, mastix, and theriak (opium? sugar?)
as drugs. He is commonly credited with being the first to regard
diabetes as a disease of the stomach; but his vague notion of a dis-
order akin to ascites hardly entitles him to a claim upon this false idea
which was productive of so much truth in the period from Rollo to
Cantani.

Claudius Galenus (born 131 A.D.) saw two patients and introduced
two ideas: first, that diabetes is a weakness of the kidneys, which can-
not hold back water and also are thirsty for fluid ; second, that the urine
consists of the unchanged drink. Galen's great authority maintained
these errors for about 1500 years, and retarded progress in the knowl-
edge of diabetes.

Chronological order here shifts the narrative to the Far East.
According to Iwai, the first oriental description of diabetes was given
in the year 200 by Tchang Tchong-king, perhaps the greatest of
Chinese physicians. "There is a disease called 'the disease of thirst,'
in which poljoiria is the characteristic symptom. One may drink as
much as ten Hters per day, which is recovered in the urine." A
Chinese medical work of about the year 600 classifies four supposed
groups of cases, and notes the s}Tnptoms of polyphagia, polydipsia,
and pol5Tiria. Still a later work mentions furunculosis. About the
fifteenth century, diabetes was attributed to wine and high living.

is a consuming heat in the bowels. The integuments of the abdomen become
wrinkled, and the whole body wastes away. The secretion of the urine becomes
more copious, and the thirst increases more and more. The disease was called
diabetes, as though it were a siphon, because it converts the human body into a
pipe for the transflux of liquid humors. Now, since the patient goes on drinking
and urinating, while only the smallest portion of what he drinks is assimilated by
the body, life naturally cannot be preserved very long, for a portion of the flesh
also is excreted through the urine. The cause of the disease may be that some
malignity has been left in the system by some acute malady, which afterward is
developed into this disease. It is possible also that it is caused by a poison con-
tained in the kidneys or bladder, or by the bite of the thirst-adder or dipsas."

HISTORY 5

Among the Japanese, Kagawa Shu-An described the s)m!iptoms of
diabetes as frequency of urination, with urine exceeding the drink in
quantity, pale color and sugar taste of the urine^ and insatiable hunger
and thirst. Homma Gencho in 1864 noted the typical symptoms, the
death from emaciation, and the urine so sweet as to attract dogs.
These accounts show obvious European influence, and the Japanese
seem to have made no original contributions. According to Iwai, this
may be explained by the rarity and mildness of diabetes among them.

In Europe, iEtius of Amida (550 A.D.) accepted the Galenic doc-
trines, but introduced into therapy three measures long used there-
after; viz., bleeding, emetics, and narcotics. According to a passage
quoted from ^tius by Donkin ( (1), p. 128), Archigenes in the second
century was the first to use opium for diabetes.

The earliest mention of the sweetness of diabetic urine is contained
in the Ayur Veda of Susruta, dating from the sixth century. The
disease bore the distinctive name of Madhumeha or honey-urine.^
Thus the most prominent clinical feature, and one of the most widely
supported modern hypotheses concerning etiology, received their first
mention in India. But Hindu medicine failed to advance beyond this
beginning, and exerted no influence on progress elsewhere.

The Arabs are credited with nothing but passing on classical learn-
ing to modern Europe, and their two greatest physicians, Rhazes
(850-992 A.D.) and Avicenna (980-1037 A.D.) are rated by Salomon
as barren followers of Galen, whose observations serve only for evi-
dence that diabetes existed among the Arabs. But Dinguizli has
translated some passages which seem to establish an advanced posi-
tion for Avicenna. In these passages, he remarks that diabetes is
generally primary, but sometimes secondary to some other disease.
He describes the irregular appetite, the great thirst, the urine equal to
the drink, the nervous exhaustion, and the loss of sexual function and
of ability to work. In suggesting that the renal weakness is due to a
relaxed state of the nerve-plexus of the kidney, he propounds the first

* A translation by Chunder Bose is as follows: "Madhumeha is a disease which
the rich principally suffer from, and is brought on by their overindulgence in rice,
flour, and sugar. The patient feels weak and emaciated, and complains of frequent
micturition, thirst, and prostration. Ants flock round his urine. Carbuncles and
phthisis are its frequent comphcations." For other quotations, see Christie.

CHAPTER I

nervous hypothesis of diabetes. "In this disease, the liver is affected,
and its r61e of provider of heat is disturbed in consequence of the
exaggeration of organic combustions. .... The relations
between the kidney and hver become irregular, in that the kidney
attracts the humors from the liver in greater quantity than it is
able to retain them." Having thus enriched the theory of the sub-
ject with the r61e of the liver, increased metabolism, and balance
between organs, he proceeds to give the first description of diabetic
gangrene, which spreads and causes death. Such inflammations are
due to retarded circulation in the limb, or to decomposition of the
blood, which results from diminution of water in the blood. Further-
more, the urine on evaporation leaves "a residue particularly scanty,
of a sweet taste like honey, and resembling particles of bran." If
this account proves authentic, it raises Avicenna to the rank of a
clinical genius; but the second period of diabetes still begins with
WilUs, because only the latter's observation influenced the further
development of the subject. Avicenna's treatment consisted in pow-
ders of fenugreek, lupin, and wormseed, in dosage increasing up to 45
gm. daily. This seems rather suggestive of veterinary medicine, but
both Dinguizli and Robin reported patients benefited. As with so
many other methods, the digestive disturbances mentioned sufl&ci-
ently explain any benefit produced by the treatment of Avicenna.

Trincavella (1476-1568), a Venetian, observed three cases of dia-
betes. In one, the etiology was attributed to persecution and grief.
In another, the relatives are said to have demonstrated the truth of the
Galenic doctrine that diabetic urine is the unchanged drink, by fre-
quently tasting the urine and finding the taste identical with what the
patient had been drinking. Cantani suggests that the drink in this
case was sweet tea.

Amatus Lusitanus and Zacutus Lusitanus, Portuguese physicians of
the forepart of the sixteenth century, named dietary, alcoholic, and
venereal indiscretions among the causes of diabetes. The latter con-
sidered the seat of the diabetic disturbance to be not only in the
kidneys but even more in the stomach; he thus holds a transitional
position in regard to theory between Galen and RoUo.

HISTORY 7

Aureolus Philippus Theophrastus Paracelsus Bombast ab Hohen-
heim (1493-1541) broke radically away from all old dogmas, in this
as in other subjects. He performed the first chemical experiment,
and, with surprisingly accurate insight, drew from this crude observa-
tion the first chemical concept of diabetes. The experiment con-
sisted in evaporating the urine; it was found that a "measure" of
urine yielded four ounces of "salt." Paracelsus therefore afl&rmed
that diabetes is a systemic disease, characterized by the formation of
an abnormal salt in the blood. The polyuria is not due to a renal lesion,
but the salt "makes the kidneys thirsty; for thirst always comes from
salt." He was accustomed to taste the urine of patients, but for some
reason failed to discover the sweetness of diabetic urine.

Geronimo Cardano (1505-1576), an Italian, claimed that a girl of
eighteen years took seven pounds of food and drink daily and excreted
thirty-six pounds of urine, thus proving Celsus' notion that the fluid
output is greater than the intake in diabetes, the excess being suppos-
edly drawn from the air. In addition to this mistake, there is evidence
that the girl did not even have diabetes; but a step forward is repre-
sented by this first record of a case history and a chnical experiment.

Rembert Dodonaeus (1517-1586), a Dutch physician, first mentioned
chyluria in a diabetic'

Johann Baptista van Helmont (1578-1644), of Brabant, followed
the chemical theory of Paracelsus and regarded diabetes as a disease
of the blood. He was the first to record an observation of diabetic
Upemia.'

Franciscus Deleboe Sylvius (1614-1672), professor at Leyden, took
a step backward, in holding that the offending substance in the blood
in diabetes is a volatile salt.

' "Albida autem urina erat, non transi)arens, et paulo quam serum lactis
tenuior."

' "Atque in diabete, totus cruor mutatur in lotium lacteum."

II. The Second or Diagnostic Period (1675-1796).

Thomas Willis (died 1675), Sidley Professor in Oxford University,
was the first Englishman to make an important contribution to the
knowledge of diabetes. This was the simple observation that the
urine is "wonderfully sweet, as if imbued with honey or sugar."' He
did not guess that the sweetness is actually due to sugar. He held to
the theory that diabetes is a disease of the blood. The water is not
properly combined with the solid matter, so that the water escapes
through the kidneys, carrying large quantities of salts with it. Per-
Jiaps there is some disorder of the kidneys also. The resulting thick-
ening of the blood causes the excessive thirst. Urine containing so
much salt should taste salty; "but why it is wonderfully sweet like
sugar or honey, this difficulty is worthy of explanation." He thinks
it may be explained by the manner in which acids and salts alter one
another's taste. Acid salts are formed in the blood in various diseases.
Also a possible source of such acids is fermentation, as of wine and cider.
Therefore immoderate use of these liquors is a leading cause of dia-
betes. It may also be brought on by bad hygiene, worry, and nervous
aiknents. Treatment should aim to thicken the blood and supply
salts. Accordingly, milk, rice, and starchy and gummy foods are
indicated; and by Umiting a patient to a diet of milk and barley-water
boiled with bread, Wilhs became the author of the first carbohydrate
or undernutrition cure. He employed Hme-water as a beneficial form
of salt; it held a high place in diabetic therapy for well over a century,
and was the first alkali to come into general use in diabetes. Certain
other drugs owed their general adoption largely to his example, even
though he was not the first to use them. Thus, his antimony treat-
ment was in favor more than a century after his death and led to some
interesting developments, and his Dover's powder and tinctura the-
baica fastened upon the medical profession an opium habit in diabetic

' "Quasi melle aut saccharo imbutam, mire dulcescere."

8

HISTORY 9

treatment which is very difl&cult to break even at the present time.
Superficially, the sweet taste of the urine appears such a primitive and
fortuitous observation as might have fallen to the credit of anybody
in the 2000 years of European medicine from Hippocrates to Willis.
But, with due allowance for the inevitable element of chance, the above
record makes it clear that this, like most discoveries, fell to the lot of
the man whose point of view and whose methods were capable of yield-
ing discoveries. It marked a triumph of modern independent thought
and objective clinical study over subservience to authority and dogma.
It was of epoch-making importance in the history of diabetes; first,
because it established a radically new and decidedly more accurate
basis for diagnosis, which had previously depended upon polyuria and
other uncertain symptoms; and second, because it led first to the
dietary treatment of RoUo and his successors and later to the experi-
mental work of Claude Bernard and all subsequent investigators of the
normal and abnormal metaboHsm of carbohydrates. It may in some
measure be due to the stimulus given by Willis that for nearly two
centuries (viz., until Bernard and Bouchardat transferred the leader-
ship to France) the important progress in the subject of diabetes was
practically confined to Great Britain.

Thomas Sydenham (1624—1689), hailed as a second Hippocrates in
general medicine, contributed nothing of value in diabetes except a
clearer definition as a disease of metabolism. Because the nutritive
elements of the blood are not properly prepared for assimilation, they
pour out through the kidneys, and the flesh and strength melt away.'
Later h3^otheses of free versus combined sugar are here anticipated.
In treatment, Sydenham prescribed narcotics and theriak; also, "Let
the patient eat food easy of digestion, such as veal, mutton, and the
like, and abstain from all sorts of fruits and garden stuff;" but no
effective dietetic treatment grew out of this advice.

Richard Morton (died 1698) likewise regarded diabetes as "a con-
tinual flow of nutritive juice pouring out through the kidneys, which

' "Sued sanguini illati per vias urinarias crudi, et inconcocti, exitum sibi
quaerunt; tuide sensim labefactantur vires, colliquescit corpus, et quasi substantia
ejus per banc cloacam exinanitur, cum siti, ardore viscerura, lunxborum coxarum-
que intumescentia, et salivae spumosae exspuitione crebra."

10 CHAPTER I

frequently befalls intellectual persons, and drinkers of brandy and
diuretic liquors."" He was the first to note its hereditary character.
Milk, diet was a feature of his treatment. He opposed the bleeding
and purging in use among some physicians.

Richard Mead (died 1754) was the first to consider diabetes a dis-
ease of the liver, and brought supposed necropsy evidence in support
of this view. On the Continent also began a careful postmortem
search for lesions causing diabetes, but nothing of significance was
found.

Matthew Dobson (1775) completed the discovery of Willis, and
with his paper in English, the history of diabetes emerges froni Latin
into the modern languages. He first grasped the fact that the sweet
substance in diabetic urine is sugar, proving this experimentally by show-
ing that such urine was subject to alcoholic and acetic fermentation,
did not coagulate on heating or addition of a mineral acid, but on
evaporation four pounds of a patient's jirine yielded a whitish cake
weighing four ounces, two drams, and two scruples. This cake
"smelt sweet, like brown sugar, and could not be distinguished from
sugar, except that the sweetness left a slight sense of coolness on the
palate." The urine of the same patient in convalescence yielded a
less abundant dark residue which was not sweet. Dobson also was the
first to discover a sweet taste in diabetic blood serum. He therefore
concluded that the sugar contained in normal chyle is assimilated by
the body, so that the trace in normal blood is so slight that its taste is
overcome by that of the salts. In diabetes this transformation is
slowed, so that sugar accumulates in the blood. Also, the quantity
of sugar in some cases is too great to be derived entirely from the chyle,
therefore sugar must be formed by some abnormal fermentation in the
body. The diabetic loses flesh and strength because of the loss of
nutritive material in the urine, therefore he should eat as much as
possible to make up for this loss."

^^ "Continuus succi nutritii fliixus per renes decurrens, qui cogitandibus, et
vini Gallici liquorumque diureticorum potatoribus plerumque accidit."

" A prototype of the modern fallacy of replacing through the diet the calories
lost in the urine.

HISTORY 11

Thomas Cawley*^ (1788) by a careful account of a single case, earned
credit for the first example of diabetes decipiens, the first diagnosis
of diabetes by demonstration of sugar alone, and the first description
of a pancreatic lesion in a diabetic necropsy. He, however, regarded
diabetes as a disease of the kidneys.

William Cullen (1709-1790) was the first to regard diabetes as a
disease of the nervous system, comparing the polyuria with that seen
in spastic states. He also wrote: "I think I have met with one in-
stance of diabetes, in which the urine was perfectly insipid; and it
would Seem that a like observation had occurred to Dr. Martin Lister.
I am persuaded, however, that such instances are very rare, and that
the other is by much the more common and perhaps the almost uni-
versal occurrence, I judge, therefore, that the presence of such a
saccharine matter may be considered as the principal circumstance in
idiopathic diabetes." Thus, Cullen and Lister called the attention

'^ This name often appears in the literature incorrectly as Cowley. The essen-
tials of his concise report are interesting to quote verbatim.

"Allen Holford, Esq., aged thirty-four years, strong, healthy, and corpulent, ac-
customed to free living and strong corporeal exertions in the pursuit of country
amusements, in December, 1787, was seized with diabetes; but the cause of the
great degree of emaciation and debiUty which gradually came on was not dis-
covered until March 20, 1788; at which time his urine was found to be sweet,
fermentable with yeast, and two pounds, on evaporation, jdelded about five or six
ounces of sweet black extract, exactly resembling that preparation of melasses
made by confectioners for children, and vulgarly called coverlid.

"Within the above mentioned period the quantity of urine evacuated was never
observed to exceed what is usual in health, or to be disproportioned to the ingesta,
though the state of it had been frequently inquired into, and even the quantity of
liquids drank and voided measured. For these reasons the quality of it was not
suspected until it became inconceivable, considering the quantity of aliment taken
in, how such a degree of exhaustion could ensue, unless the body was drained by
the quality of what was rejected as apparently excrementitious.

"Variety of medicine, the usual consequence of inefficacy and despair, were suc-
cessively administered. Decoction of bark with vitriolic acid and alum, with
astringents and aromatics, with chalybeates, with sacc. saturni and opium, and with
cantharides, together with cold bathing in salt water, were theprincipalmeans used,
and at first had a very good effect; but soon afterwards every medicine disagreed
with the stomach, and the patient gradually sunk and died on the 18th of June."

"The pancreas was full of calculi, which were firmly impacted in its substance.
They were of various sizes, not exceeding that of a pica, white, and made up of a

12 CHAPTER I

of the medical profession to the possible existence of diabetes insipi-
dus.i' GuUen first added the adjective "mellitus" to the name of the
disease. Cullen's theory of diabetes was that of Dobson, with whom
he had discussed it. "I formerly communicated this idea to Dr.
Dobson, who adopted it, and published it; but I must confess that
the theory is beset with difficulties, which cannot at present be solved."
He gave a wholly pessimistic view of the treatment and prognosis;
he had tried the known methods on twenty diabetic patients and failed
to save any of them.

John Brown (1735-1788) conceived life as motion. Diabetes, as a
disease of weakness, should be treated by exercise, which should be
neither too slight nor too severe. But Brown's treatment was inferior
to that of his predecessor Celsus, in that abundance of food and drink
was also prescribed for strengthening.

Johann Peter Frank (1745-1821), the most renowned German phy-
sician of his time, gave the name of diabetes decipiens, or deceptive
diabetes, to the condition of glycosuria without polyuria described by

number of lesser ones, which made their surface rough, like mulberry stones; and
in all respects they appeared analogous to the calculi which we sometimes meet
with in the salivary ducts. The right extremity of the pancreas was very hard,
and appeared to be scirrhous."

"Experiment I. — A small quantity of urine, set by in a phial, spontaneously
entered into the viaous, and then into the acetous fermentation, discharging a
great quantity of mephitic gas. A white cloud formed in the center, which gradu-
ally fell to the bottom in the form of a white precipitate. In short, the whole of
this experiment corresponded with Dr. Dobson's."

"Experiment IV. — ^A small quantity of the extract put into spirit of wine neither
dissolved nor communicated any colour to it, but immediately became very hard
and brittle.

"It appears, by the last experiments, that the extract consists of sugar united
with gummous or coagulable matter, all of which ought to remain in the body for
its support, and that little of what is excrementitious passed through the kidneys
but superabimdant water, the vehicle of this nutritious matter."

^^ They did not clearly demonstrate the existence of such an entity, for Bard-
sley (mentioned by Watt, p. 14, who gives the above quotation) criticized their
findings by showing that a urine with no perceptible sweet taste might form
more or less oxalic acid when examined chemically. This formation of oxalic acid
on treatment with a mineral acid was the first chemical method for the demon-
stration of sugar in urine, and was used by RoUo and his immediate successors.

HISTORY 13

Cawley. He also established the definite division and nomenclature
of diabetes insipidus or spurius and diabetes mellitus or verus.

Francis Home diflCerentiated "watery" and "milky" diabetes." He
proved experimentally that the urine of a diabetic patient was not in
excess of the fluid in food and drink. He isolated sugar from the urine
of two patients, respectively an ounce and an ounce and a half of
sugar to the pound of urine. Addition of yeast to the urine was fol-
lowed by fermentation; the urine lost its sweetness and acquired the
taste of small beer. He failed to confirm Dobson's observation of the
sweetness of diabetic serum. He upheld Dobson and CuUen's theory
of diabetes as a defective assimilation of food. The sweet urine,
milky in some cases, was evidence to him that vegetable foods are not
properly assimilated in diabetes; the sweet chyle, which is the first
product of digestion, is not converted into ammonium salts as it nor-
mally should be. Therefore diabetes should be curable by strict meat
diet; but he was unable to make this theory succeed in practice, and
he went on to try a multitude of drugs without result. Given suffici-
ent courage or skill to build on this theory a successful practical
method, he might have been the founder of the new era of therapy.

^*The relatively frequent mention of milky urine among early writers is re-
markable. Perhaps the appearance was due to fermentation. Whether in the
absence of dietary regulation there may have been occasionally a true visible
lipuria is a possible question of interest.

III. The Third Period, or Period of Empiric Treatment
(1796-1840-50).

John Rollo, a surgeon-general of artillery in the English army,
ventured to try an entirely original method on the first case of dia-
betes that he had ever treated. "For the case I had seen at Edinburgh,
and Dobson's account, with Dr. CuUen's opinion, had prepossessed
me with the idea of the disease being a primary and pecuUar affection
of the stomach" ( (2), p. 5)." This first patient, a certain Captain
Meredith, treated in 1796, shares some of his physician's fame, not
unjustly, in view of what he went through. The treatment began
with bleeding, which is said to have made the patient feel better.
Confinement to the house was ordered, preferably to one room, with
the utmost possible quiet and avoidance of exercise. The bill of fare
was as follows: "Breakfast, I5 pints of milk and J pint of lime-water,
mixed together; and bread and butter. For noon, plain blood pud-
dings, made of blood and suet only. Dinner, game, or old meats,
which have been long kept; and as far as the stomach may bear, fat
and rancid old meats, as pork. To eat in moderation. Supper, the
same as breakfast." The skin was to be greased daily with hog's
lard, flannel worn next the skin, and an ulceration about the size of
half a crown to be maintained opposite each kidney. At first, kali
sulphuratum was ordered several times daily, but later this was ex-
changed for "hepatised ammonia" (ammonium sulphide), "a medicine
proposed by Mr. Cruikshank, who was of the opinion that it might
prove a more certain and active medicine than the other on the stom-
ach, in diminishing its action, as well as that of the system in general."
Wine of antimony and tincture of opium were to be taken at bedtime,
and "in reserve, as substances diminishing action, tobacco and fox-
glove." Captain Meredith's age was thirty-four, and his diabetes of
seven months' standing, apparently moderate in degree. He steadily

^' This rules out the statement by various authors that Rollo received his stimu-
lus from Home.

14

HISTORY 15

improved, in spite of occasional indulgence in apple pie or beer. Along
with the gain in strength and disappearance of symptoms, Rollo noted
diminution in the quantity and sweetness of the urine, in the amount
of sugar obtained on evaporation, and in the oxalic acid test. After
cessation of glycosuria, the strict diet was gradually relaxed, and it is
complimentary to RoUo's judgment that the first vegetables permitted
were cabbage, boiled onions, salad, mustard, common radish, and
horse-radish. The patient resumed his military duties. Rollo under-
took his second case, that of "a General Officer." Here the diabetes
was of three years' duration, and the patient, aged fifty-seven, re-
peatedly broke even the rather mild regimen imposed, so that he
ultimately died.

Various other matters of interest are contained in Rollo's book.
The diuretic action of sugar is clearly recognized. ((2), p. 24) : "The
serum of the blood apparently containing less saccharine matter than
the urine, may depend on the power of the kidneys in separating it
in common with the other saline matters of the blood; but proving a
new and peculiar stimulus, their action is increased, and the saccharine
matter consequently separated speedily and in proportion to its for-
mation in the stomach." (P. 37) : "A diet of animal food, as rancid as
possible, was proposed in our case, with the view of preventing the
formation of sugar in the stomach, and by that means to remove the
peculiar stimulus which supported the increased action of the kid-
neys." A number of other physicians wrote enthusiastically concern-
ing the benefits of the new method. Currie (pp. 147 and 184 of
Rollo's book, 1798) reported experiments of weighing ingesta and
egesta, weighing the patient before and after bathing, etc., to refute
the ancient error of excess of fluid output over intake. Marshall de-
scribed a necropsy showing lipemia, "chyle in the subclavian vein;"
and "there appeared to be no proper blood in the body, but instead of
it, a hquid nearly resembling well made thin chocolate. All the veins
were filled with this singular brown blood, which had a sickly, sweet-
ish, slightly sour smell (not tasted)." On page 331 is the first re-
corded observation of an important phenomenon, — a diabetic aged
twenty-five, "with the odor of decaying apples in his breath." The
letters from physicians show that diabetes was a rarity and a curiosity
to them. Dr. Monro is quoted (p. 364) in a statement of the nature of

16 CHAPTER I

diabetes, which may well bear comparison with present-day views:
"Were I to give a theory of this wonderful disease, I would say that it
arises from a defect of the animal or assimilatory process, by which the
aliment is converted into the nature of our body." RoUo's theory was
inferior to that of Dobson and Monro. He held that diabetes is a
disease of the stomach, with increase of its activity, secretion of an
abnormal gastric juice, and probably increased activity of the lac-
teals; that "the saccharine matter is formed in the stomach, and
chiefly from vegetable matter." The source of sugar was to be cut
oif by restricting the diet to animal food; but milk was provisionally
included under animal food, and, to indulge the patient, a little bread
was permitted. Also, the abnormal activity of the stomach should be
depressed, so as to check bulimia and restore the secretion of a normal
gastric juice. Therefore, drugs were chosen to produce anorexia and
nausea — ammonium sulphide, antimony, opium, digitalis, tobacco.
The use of rancid fats in the diet was for a similar purpose. Fat in-
deed was responsible for the first fasting treatment of diabetes (RoUo
(2), p. 36). "Thus Villanovanus relates that a certain man, affected
with this disease, eat pot-bread dipt in lees of oil; and that a woman in
the like case drank twice the melted fat of beef, with a like quantity
of hot oil; and that both these patients contracted so great a loathing
of food, that neither of them eat anything for five days, and so got rid
of their distempers." It so happened, therefore, that the very incor-
rectness of RoUo's theory aided in his therapeutic success. From the
results achieved with his method by himself and others, he drew the
conclusion (p. 141) that "diabetes mellitus is so far understood as to be
successfully cured."

Dupuytren and Th6nard reported good results from the RoUo diet
in France, considering it as specific for diabetes as quinine for malaria;
yet they recognized that the cure is never complete, as patients re-
lapse whenever they discontinue the diet. They investigated the
properties of diabetic urine, demonstrating that on fermentation it
yielded carbon dioxide and alcohol; this was considered to prove the
presence of sugar, but this sugar was thought to be of a peculiar kind
with little taste.

Nicolas and Gueudeville held a theory similar to that of RoUo.
They regarded diabetes as a disorder of intestinal digestion; the chyle

HISTORY 17

is normally composed of nitrogenous substances, but in diabetes it
contains imperfectly elaborated materials saccharine in character and
unsuited for the nutrition of the body.

Robert Watt (1808), a Scotchman, reported benefit from treating
diabetes with the Rollo diet, bleeding, bhstering, antimony powders,
and sometimes mercury. Both food and drink were severely restricted
in quantity. Watt's clinical ability, and the position properly belong-
ing to him in the history of this subject, may be indicated by quota-
tions from his remarkable little book." His admonitions may be
profitable to many even at the present time.

Thomas Christie (1811) first brought to European notice the fact
that diabetes was known to the ancient Hindus. He described the
frequency of diabetes in Ceylon, and his success with the Rollo treat-
ment there.

"Watt, preface: "The rapid restoration of health after venesection, blistering
and an abstemious diet in cases, where from the great prostration of strength and
excessive emaciation, a stimulating mode of treatment seemed indicated, dis-
closes views of the animal economy by no means favourable to some modern opin-
ions. It is to be feared that a dread of debility and an emaciated state of body,
from an inflammatory, not a hectic cause, have sometimes deterred practitioners
from employing depletion, and the patient has been quietly resigned to his fate.
As diabetes is so obviously aggravated by too much aliment or stimuU, and as
there is such an attendant buUmia, the first aim of the practitioner should be
to remove a portion of that food, which, since it does not nourish, must oppress
and injure the system. Animal diet accomplishes this object to a certain ex-
tent, for during its use, the quantity of ingesta is necessarily diminished, and a
partial abstinence is enforced. More might have been done if, instead of an
exclusive confinement to animal food, the quantity of ingesta were gradually
diminished, till no more were received than the digestive organs could easily
prepare, and the functions of assimilation successfully convert to the support
and nourishment of the system. Artificial depletion may, in some measure,
supersede the necessity of too strict adherence to an abstemious diet; but the end
will imdoubtedly be more easily, and effectually accomplished if the patient can
exert the requisite fortitude to resist the cravings of appetite, and to repress urgent
thirst. These indulgences increase the flame, which sooner or later consumes the
patient. We aid the cure by a diminution of the supply, and the same means pro-
tract the fatal period, or smooth the passage to the grave, when a cure is beyond
the reach of art."

Watt (p. 29 ff.) described the treatment of a laborer suffering from moderate
diabetes. The man was bled daily, the quantity of blood taken being generaUy

18 CHAPTER I

Chevreul in 1815 demonstrated that the sugar of diabetic urine is
identical with glucose.

Latham (1811) distinguished two forms of diabetes, the saccharine
and the seirous. Likewise Gregory (1825) described the differences
between diabetes mellitus and diabetes insipidus. Such observa-
tions were of importance in settling the existing doubts among the
medical profession as to the decisive import of glycosuria for the diag-
nosis of diabetes.

Pelham Warren (1813) may be mentioned as the leading English
opponent of the Rollo treatment. He regarded dietary restriction as
of merely secondary importance, and voiced the frequent objection
that patients would not adhere to such a diet. He placed chief de-
pendence on large doses of opium, by which, without dietary regula-
tion, he obtained diminution of glycosuria and polyuria. Some
authors have referred to him as the originator of opium therapy. He

fourteen or eighteen ounces, but on one day twenty-four ounces. The bleedings
were well borne, and after^ twelve days there was marked improvement. Anti-
mony powders were also used, and the patient in consequence "was very sick and
uneasy all day; had no appetite for food." Again (p. 35): "The antimonial
powders appeared to have a more decided effect. They produced very severe
sickness, vomiting, and commotion in the stomach and bowels. The night after
taking these, the urine was greatly reduced, and next day he found himseK un-
commonly weU. On repeating them, they had not such violent effects, nor was
the relief obtained so decisive. . . . Anything which produces sickness has
a temporaiy effect in relieving diabetes, by diminishing the quantity of ingesta.
The antimonial powders seemed to possess no other specific action. During the
two days he was under their influence, he vomited everything, and was not dis-
posed to take either meat or drink, hence when the supply is cut off, the excretion
must diminish of course." (P. 204) : "The loss of balance between the digestive
and assimilative organs may be produced in two ways" (underf unction of lungs or
overfunction of lacteals). (P. 205) : "In some diseases the receptive power is not
only continued but even increased, whUe the assimilative powers remain at or
below their normal level." Finally, (p. 212): "Diet. From the very nature of the
disease, abstinence becomes an indispensable part of the practice. This doctrine,
however, is often very contrary to the feelings of the patients, who are apt to urge
in their defence that nature is the best judge of what is necessary for their support.
They feel weak, they have a strong craving for food, and they can see no reason
why they should be deprived of what makes other people strong. These argu-
ments are frequently repeated, though every meal might convince them that it
has added to their burden and not to their strength."

HISTORY 19

failed to take account of the effect of opium upon appetite, and he may
be considered the founder of the erroneous belief, still widely prevalent,
that opium has an actual specific effect upon diabetes.

RoUo's treatment seems to have met with chiefly an adverse judg-
ment in Germany." It never gained general adoption by the medi-
cal profession of any country, unless perhaps England; and though
it always had eminent supporters, and more or less restriction of carbo-
hydrate continued to prevail, yet the weight of opinion and practice
even in England gradually turned against strict animal diet. The
decline in popularity may be attributed to the crudeness and imper-
fections in the method itself, the careless and faulty application of it
by most physicians, the rebellion of patients — ^who generally, sooner
or later, secretly or openly broke the intolerable dietary restrictions
and relapsed — the failure of the method to check the severest cases,
and the frequent bad results, well understood nowadays, of changing
diabetic patients suddenly from mixed diet to strict protein-fat
regimen.

Prout, though transitional in time and influenced in his later years
by Bouchardat, may be mentioned as closing this period. Naunyn
( (5), p. 388) credits him with being, in the 1820 edition of his book,
the first to restrict protein in diabetes; but such instructions (1848
edition, p. 40) were intended only to forbid overloading the stomach
at any one time, so that Front's advice was not superior to RoUo's and
far inferior to Watt's. His treatment was based on the theory (p. 38)
"that diabetes is nothing more nor less than a form of dyspepsia;
that this dyspepsia principally consists in a difficulty of assimilating
the saccharine alimentary principle." He did not approve of strict
animal diet, but gave especially green vegetables with it. He (p. 44)
introduced the use of bran bread, to be made with eggs and milk, the
bran being finely ground to avoid irritation of a sensitive intestine,^'
and washed in a cloth till the water came through clear to remove

^' Cf. unfavorable experiences reported by von Stosch, Wolff, and Horn, ref. by
Ebstein((2), p. 11).

'* Camplin (1858) stated that the use of bran for diabetic bread had been known
for a long time, but it was not highly considered. He was a diabetic treated by
Prout, and suffered diarrhea from bran bread; therefore he originated the plan of
having the bran ground very fine in a special mill.

20 CHAPTER I

starch. He limited drink as well as food. He employed bleeding,
Dover's powder, antimonials, and other drugs, but cathartics only as
needed to regulate the bowels. In thirty years of practice he saw 700
diab.etics. He considered that cold, dampness, or malaria brings on the
disease in predisposed persons. He described the frequency of phthisis
as a fatal complication, the liability to sudden death from indigestion,
travel, or exhaustion; and in particular, he was the first to mention
coma as the typical termination of diabetes, as follows: (pp. 28-29)
"The person and breath of the patient often exhale a sweetish hay-
like odour. Accompan3dng these bodily symptoms there is great de-
pression of spirits and despondency. .... The breath becomes

short, and there is more or less of cough and expectoration

The emaciation and debility now rapidly approach the maximum; the
tongue and fauces assume a dark red colour, and often become aph-
thous; the urine generally diminishes in quantity, and loses much of
its saccharine property; the feet and legs become edematous; and,
finally, after almost a total suppression of the renal secretion, the
patient becomes comatose, in which state he expires." Also (p. 61.) :
"In young children, the sudden withdrawal "of fluids, as well as the use
of opium, require caution, from the tendency of these expedients to
cause a suppression of urine, which is almost certain to terminate in
coma and death."

IV. Modern or Experimental Period.

Though this period began in the decade 1840 to 1850, the way was
prepared, as usual, by a few brilliant forerunners, who may properly
be included here.

Lavoisier" (1743-1794), who discovered the most important
properties of oxygen, substituted chemical union for the phlogiston
hypothesis, and determined that plants consist essentially of carbon,
hydrogen, and oxygen, while animals contain also nitrogen, pointed out
the relation of oxygen to the processes of life. He proved that it,
and not nitrogen, is essential for respiration. He recognized that
animal life and heat are dependent on oxidation. He performed the
first experiments concerning human respiratory metabolism, and
actually obtained correct values for the normal oxygen consumption
of man, and demonstrated the increase due to cold, work, and diges-
tion. Such an achievement is a most remarkable display of genius in
a man whose work preceded RoUo's publication, and whose career was
untimely ended by the guillotine of the French Revolution. Further
research was lacking in this line until Regnault and Reiset in 1849
conducted experiments with a respiration chamber for animals.

Tiedemanh and Gmelin (1827) in animal experiments proved that
sugar is normally formed from starch in digestion. By the fermenta-
tion test they also demonstrated sugar in the portal and systemic
blood of animals after carbohydrate feeding, but supposed it to be
absorbed through the chyle. .

Ambrosiani, also Maitland,^" by the same method discovered the
presence of fermentable sugar in the blood of diabetic patients, though
Claude Bernard criticized their results because white of egg was used
to clarify the solution. M'Gregor claimed to find sugar in the vomitus
of a diabetic who for three days had received only roast beef and water,
thus, supposedly demonstrating the origin of diabetes in an abnormal

'^ See Lusk, Chapter I.
^^ Mentioned by M'Gregor.

21

22 CHAPTER I

gastric function. He also reported the presence of sugar in diabetic
saliva and feces. Also, by fermentation, he demonstrated sugar in the
blood of a considerable number of his diabetic patients, and found
traces in the blood of normal persons during digestion of starch. Mag-
endie and von Frerichs confirmed these blood sugar findings.''^ Mean-
while Thomson had attempted the first quantitative determination,
fijiding by fermentation only 0.03 to 0.06 per cent of sugar in chicken
blood.

Other movements in science about this time must be borne in mind
in connection with the remarkable new developments in the field of
diabetes: Wohler's synthesis of urea in 1828, breaking down the sup-
posedly absolute barrier between the domains of the organic and inor-
ganic; the cell theory enunciated by Schleiden in 1838 for plants, and
by Schwann in 1839 for animals; the beginning of Virchow's work on
cellular pathology with his appointment as Privatdozent at Berlin in
1847; and meanwhile the laying of the foundations of physiological
chemistry by Liebig. In addition to the deeper problems thus thrown
open, certain chemical tests deserve notice; these were the polari-
metric determination of sugar discovered by Biot in 1833, the first
copper reduction qualitative test devised by Trommer and announced
after his death by MitscherUch in 1841, and the quantitative method
of Fehling in 1850. It is hard to overestimate the important influence
of these easy and striking sugar tests upon the development of the
theory of diabetes. Also, by furnishing the first means for the accurate
qualitative and quantitative detection of sugar even in small quanti-
ties, they had a great and immediate effect on both diagnosis and
treatment.

Claude Bernard contributed nothing directly to the treatment of
diabetes, but stands as an epoch-making figure of the new period be-
cause of the extensive physiological researches by which he not only
founded modem knowledge of carbohydrate metabolism, butjalso
clearly established animal experimentation as a method for solution of
the problems involved. His scientific career began in 1847, his first
work being the demonstration of sugar in the right-heart blood of dogs
fed exclusively on meat. This inconclusive experiment seemed then

*^ For other early literature see von Mering ( (1), p. 386).

HISTORY 23

to overthrow the prevailing doctrine that only plants and not animals
can form sugar from non-carbohydrate materials. By this and other
experiments Bernard founded the theory of sugar formation from pro-
tein, which was not to receive actual proof until some years later.
He performed the first reasonably accurate quantitative determina-
tions of blood sugar, some of his values being too high, presumably
because of injury and excitement of the animals, but other figures,
such as 0.107 per cent, being of a character now recognized as normal.
He discovered glycogen and the glycogenic function of the liver; he
considered that glycogen is formed from either the carbohydrate or
the protein of the food, and that the liver from its glycogen suppHes
sugar to the circulation in the intervals between digestion. He ob-
served sugar formation from glycogen in the liver post mortem, and
proved that the process was due to a diastatic enzyme, which was held
to be the agent of this action also during life. He discovered curare
glycosuria, and, more important, the glycosuria produced by puncture
of the floor of the fourth ventricle, giving the first experimental foun-
dation for the conception of nervous glycosuria. To Bernard, dia-
betes and piqiire glycosuria were temporary and permanent forms of
the same thing. The nervous irritation was supposed to cause
splanchnic vasodilatation and hyperemia of the liver; this produces
increased contact between liver glycogen and blood diastase, and the
resulting acceleration of glycogenolysis floods the body with sugar,
the excess of which flows away in the urine. It was thus a pure over-
production hypothesis, and the liver was in Bernard's opinion the
organ principally concerned.

Mialhe in 1845 announced the discovery of the diastase of saliva.
Apparently as an outgrowth of his diastase studies, he set up the hy-
pothesis that diabetes is a primary acidosis, that the blood of patients
has an acid reaction due to ingestion of too much acid, or to deficient
sweating and the resulting retention of acids; and he introduced a
treatment with large doses of alkali, especially sodium bicarbonate and
magnesium hydrate. Though claiming some benefits at first, he and
those repeating his attempt soon met failure. Under the tests of
Bouchardat, Griesinger, Kulz, and others, both theory and therapy
fell. Later Mialhe (3) concluded that the primary cause of diabetes
does not consist entirely in an abnormal composition of the blood, but

24 CHAPTER I

in an essential nervous disorder. The fallacious comparison between
the diabetic process and the r61e of acids in the hydrolysis of starch or
glycogen in vitro has caused such a theory to reappear in various forms
from that time to the present.

Though Bouchardat (1806-1886) read his first memoir to the Acad-
emy of Sciences in 1838, and the final edition of his book appeared in
1875, he came into prominence thrbugh important contributions in the
decade 1840 to 1850. Like Rollo and aU other founders of the dietetic
treatment, he considered diabetes a disease of digestion. According to
his theory, normal gastric juice has no action upon starch, which is di-
gested in the intestine; but in diabetes, an abnormal ferment digests
starch in the stomach, and glycosuria, polyuria, and other symptoms
result. He claimed to demonstrate the presence of diastase in the
vomitus of diabetics and its absence in that of normal persons."^
Hypertrophy of the stomach and atrophy of the pancreas in diabetic
necropsies were also held to support his theory; and he was thus
the first to suggest an influence of the pancreas in the causation
of diabetes, and the originator of the attempt to produce it by pan-
createctomy in dogs.^* For sugar determination in urine, he used
fermentation, the polariscope, and the Frommherz copper reagent.
By the fermentation method he showed the presence of sugar in dia-
betic blood, but found none in normal blood. At how low an ebb
was the Rollo treatment at this time is shown by the pleading and

'^^ Various other authors reported similar results: cf. Griesinger, pp. 41-42.

^' Some authors attribute the first pancreatectomy to Brmmer in 1686, but his
extirpation aimed only to produce hypertrophy of the duodenal glands named after
him, and involved less than half of the pancreas. Bouchardat ((2), p. 108)
ascribed to Haller (1708-1777) the observation that depancreatized dogs show
polydipsia, polyphagia, emaciation, and death. This statement has been widely
copied in the literature. But pancreatectomy to the point of diabetes was scarcely
possible at such an early datCj and as Haller apparently never published any such
work (cf. Sauerbeck), the entire myth seems to have originated in a mistake of
Bouchardat. The first attempt at total extirpation and the first idea of producing
diabetes by this means were represented in Bouchardat's publication in 1846 of
experiments undertaken with Sandras to support the pancreatic origin of diabetes.
The dogs did not survive pancreatectomy, and ligation of the pancreatic duct did
not produce diabetes. The undeveloped state of surgery therefore barred Bou-
chardat from reaping the fruits of his brilliant intellectual perception in this field.

HISTORY 25

arguments of Bouchardat ( (1), p. 10). He begs all friends of truth
to hear him; whatever be the original cause of glycosuria, diabetics,
who otherwise all die, are actually saved when his dietetic treat-
ment is used. Bouchardat in the clinical field ranks with Claude
Bernard in the experimental field. He is easily the most brilliant
clinician in the history of diabetes. He resurrected and transformed
the Rollo treatment, and almost all the modern details in diabetic
therapy date back to Bouchardat. He was first to insist on the need
of individualizing the treatment for each patient ( (2), p. 150). He
disapproved the rancid character of the fats in the Rollo diet, but
followed an intelligent principle of substituting fat and alcohol for
carbohydrate in the diet. H.e forbade milk because of its carbo-
hydrate content. He urged that patients eat as little as possible,
and masticate carefully; also (1841) he inaugurated the use of oc-
casional fast-days to control glycosuria. Subsequently he noted the
disappearance of glycosuria in some of his patients during the pri-
vations of the siege of Paris. Though the introduction of green
vegetables is credited by Prout (p. 45) to Dr. B. H. Babington, the
honor of thus successfully breaking the monotony of the Rollo diet
.properly belongs to Bouchardat.- He recommended them as furnish-
ing little sugar, a little protein and fat, but especially potassium, or-
ganic acids, and various salts. He also devised the practice of boiling
vegetables and throwing away the water, to reduce the quantity of
starch when necessary. As a similar trick ( (2), p. 217) he "torrefied"
(i.e., charred and caramelized) bread to improve its assimilation;
possibly this is the origin of the widespread medical superstition that
diabetics may have toast when other bread must be forbidden. He
invented gluten bread; this started the idea of bread substitutes,
from which sprang the bran bread of Prout and Camplin, Pavy's
almond bread, Seegen's aleuronat bread, and the numerous later
products. Bouchardat also first introduced the intelligent use of exer-
cise in the treatment of diabetes, and reported the first clinical ex-
periments proving its value. He showed that carbohydrate tolerance
is raised by outdoor exercise; and to a patient requesting bread, he
replied ( (2), p. 228) : "You shall earn your bread by the sweat of your
brow." There is a modern sound to his complaints ( (1), p. 47) of the
difficulties of having treatment efficiently carried out in hospitals, of

26 CHAPTER I

the lack of adequate variety of suitable foods, of deception by patients,
and of how, even when improved in hospital, they break diet and
relapse after returning home. He advocated ( (2), p. 330) daily test-
ing of the urine, to keep track of the tolerance and to guard against a
return of sugar without the patient's knowledge. He followed Mialhe
in giving alkalies, viz. sodium bicarbonate up to 12 to IS gm. per day,
also chalk, magnesia, citrates, tartrates, soaps, etc., also ammonium
and potassium salts; he found them often beneficial to the patients
but not curative of the glycosuria. He told a patient ( (2), p. 120):
"You have no organic disease; there is merely a functional weakness
of certain parts of your apparatus of nutrition. Restore physiological
harmony and you will attain perfect health . " He used glycerol for
sweetening purposes, and introduced both levulose and inulin as forms
of carbohydrate assimilable by diabetics, for reasons which well illus-
trate his intellectual keenness. On giving cane sugar to diabetics,
he had found only glucose excreted. Was the levulose utilized or
changed into glucose? Levulose proved under certain conditions to be
more easily destroyed in vitro than glucose. Accordingly he gave
levulose and inulin to diabetics, and found no sugar in the urine.
Therefore he recommended levulose for sweetening purposes, and
inulin-rich vegetables for the diabetic diet.

Sir Henry Marsh (Dublin, 1854) criticized the RoUodietas impossible
to follow because of the indigestion and repugnance to food resulting,
but he followed the Bouchardat plan with vegetables, and also used
exercise, warm clothing, and baths, restriction of fluid intake, Dover's
and James' powders, and alkahes (lime-water and hartshorn, recom-
mended by CoUes). He condemned bleeding, and found opium tem-
porary in effect. He noted that an attack of vomiting frequently
leads to death; also, "I have seen three cases of diabetes terminate
in fatal coma."

Fetters (1857), in the clinic of von Jaksch, investigating the peculiar
smeU noted by various authors, obtained from the urine of a coma
patient a small quantity of a liquid giving the reactions of acetone.
An extract of the limgs also jdelded acetone. He therefore attributed
the cause of coma to poisoning by acetone produced by digestive dis-
order. Kaulich distilled 700 pounds of diabetic urine, and purified
enough acetone to identify it by elementary analysis.

HISTORY 27

Trousseau condemned the Rollo diet. "I cannot too emphatically
raise my voice against the abuse of giving an exclusively animal diet
in diabetes." Intolerable loathing and impairment of health were
alleged against it. Trousseau followed Bouchardat's method, and
especially advocated exercise; but he also allowed fruits and even a
small quantity of bread, and confessed that patients in the emaciated
stage were beyond hope. He was the first to mention bronzed
diabetes.''*

Piorry of Paris, "a man who loved to turn everything upside down,"^'
brought into some prominence in 1857 a notion which was more ex-
cusable when first suggested by Chevallier in 1829. Since sugar is lost
in diabetes and is indispensable to life, it was proposed to replace the
loss by feeding sugar. Piorry gave only a very incomplete description
of one case, apparently mild, which he treated by almost complete
withdrawal of fluids, and by giving daily 125 gm. of sugar candy "and
two portions of meat." The polyuria necessarily ceased, and the
sugar excretion remained high in percentage but diminished in total
quantity. If the author's statement represents the entire diet, his
treatment was a crude carbohydrate and undernutrition cure. It had
disastrous consequences. Owen Rees and others are said to have
taken it up. Schiff — a, physiologist of some repute, an opponent of
Bernard on certain details of the glycogenic hypothesis, and a careful
investigator of nervous glycosuria, and one of those who removed the
pancreas (in birds) without discovering diabetes — also followed it, and
upon becoming diabetic, he applied this treatment to himself. Al-
though the diabetes had appeared late in life, it ran a quickly fatal
course, apparently because of the treatment.^* Naunyn ( (5), p. 383)
gives another example of injury from this treatment, as applied by a
quack. Though such a method now seems foolish, it should be noted

^* (P. SOI) : "I was struck by the almost bronzed appearance of his counte-
nance, and the blackish color of his penis." Autopsy showed a cirrhotic liver
twice the normal size.

^* Griesinger, p. 67. The quack practice of compelling patients to drink their
own urine is mentioned as something similar.

^'Naunyn ( (5), p. 388). It is interesting that Schiff (p. 128) had described a
slight alimentary glycosuria in himself and his brother, without suspecting its
warning significance.

28 CHAPTER I

that the orthodox treatment of severe cases has represented a similar
attempt to fill a sieve — the calories lost in the urkie being replaced by
fat in the diet, which merely brings the fatal end more slowly and in a
different form than does sugar.

Griesinger in 1859 published an analysis of 225 cases of diabetes;
and though only eight were his own and the others all from the litera-
ture, his contribution was valuable for chnical experiments and sound
judgment. He compiled the first evidence indicating excess in sugars
and starches as a cause of diabetes, but concluded that it could not
be the most important cause, or many more persons and some entire
races would have diabetes. He overthrew various current errors, but
somehow convinced himself in painstaking experiments that diabetics
may excrete large quantities of sugar in the sweat, as reported by
several other authors. From the negative findings in necropsies,
he regarded diabetes as generally a functional disorder. His most
notable achievement was the demonstration, in three separate experi-
ments on a single patient, of sugar excretion equalling exactly 60 per
cent of the protein of the diet. "These facts, remaining constant under
varied conditions, cannot be accidental; they seem much more to con-
tain the law of the relation in which, in this individual on exclusive
meat diet, the production and excretion of sugar stands to the quanti-
ties of ingested meat."

Frederick William Pavy" (1829-1911), in the year that he received
his doctorate (1853), visited Claude Bernard. He soon became one of
the latter's opponents on the glycogenic theory, and, in particular,
overthrew Bernard's claim that the hepatic or right-heart blood of a
fasting or meat-fed animal contains notably more sugar than the sys-
temic or portal blood. He accepted Bernard's view that diabetes is
essentially a disorder of the liver, but denied that the hver normally
supplies sugar to the circulation, and maintained that sugar is trans-
formed in passing the intestinal wall, that sugar reaching the circula-
tion as such is non-assimilable, and that the formation of any large
quantity of sugar by the liver during Ufe would make everybody
diabetic. His theories were largely incorrect, but his experimental
work was scrupulously careful and exact and still furnishes useful

^' See article by Hopkins.

HISTORY 29

information. The study of diabetes was the dominant interest of his
life; and though a clinician with a large diabetic practice, he has the
credit of perceiving that progress could come only from fundamental
physiological investigations. The flippant remark of Sir WilUam
Gull,28 "What sin has Pavy committed, or his fathers before him, that
he should be condemned to spend his life seeking for the cure of an
incurable disease?" is a compliment to Pavy rather than to its author.
Clinically, Pavy proved the transitory nature of the apparent benefit
from opium. He took a step backward by ignoring the quantity of the
diet aside from carbohydrate. He was among the first^' to make the
following observation ((1), p. 167): "Another feature of peculiarity
belonging to the complaint, is the inabihty that is experienced to ren-
der the urine alkaline by the administration of the fixed alkalies and
their vegetable salts. Although I have given the carbonate of soda to
the extent of four drachms a day; the acetate of potash, half an
ounce; the tartrate of potash and soda or Rochelles salt, six drachms,
and even an ounce; and the citrate of potash, six drachms; yet, I
have never succeeded in rendering the urine alkaline, or in any way
approaching this character."

Seegen was also prominent in the battle over the glycogenic hy-
pothesis. He laid down the principle that every prolonged glycosuria
should be considered an incipient diabetes. His therapy was retro-
grade in two points: he ignored the total quantity of protein and fat
ingested, and lie denied the value of exercise, in the belief that it was
based on a false theory.

Von Pettenkofer and Voit published the first study of the respiratory
metabolism of a diabetic patient. They made the interesting remark
that they dared not inflict much fasting on a diabetic, because of the
great hunger and the difliculty of rebuilding lost tissue. Their work
was originally supposed to show a subnormal oxygen consumption by
the diabetic. Reynoso had previously attributed diabetes to dimin-
ished respiration. Ebstein (1836-1912) devoted extensive labor to the
attempt to prove that as CO2 inhibits the diastase of saliva, pancreatic
juice, and organ extracts, so also it inhibits diastase in the living body,

="8 Cf. Editorial, J. Am. Med. Assn., 1913, Ix, 1159.

^'For earlier, less definite observations, cf. Griesinger, p. 59.

30 CHAPTER I

and that diabetes is due to abnormal diastatic activity resulting from
subnormal production of CO2 in the tissues. In treatment he advised
the usual diet, also carbonated waters. He (1) claimed priority as
being the first to point out the danger of coma when antidiabetic diet
is suddenly begun. He opposed inanition, but considered exercise
beneficial through increased CO2 production. Schnee and a few others
followed this doctrine.

Kussmaul, a pupil of von Frerichs, in 1874 gave the first detailed de-
scription of diabetic coma, distinguished it from pulmonary disease,
uremia, and other terminal processes, called attention to the char-
acteristic dyspnea, and from the physiological action of acetone ob-
served in man and animals cast doubt on acetone intoxication as the
cause of the condition.

After Bouchardat, the most powerful impetus to the rigid dietetic
treatment of diabetes came from Cantani (1837-1893). A pupil
of von Jaksch, he was at once a clinician and an enthusiastic chemist
and theorist. His preface preaches that, however great the achieve-
ments of morphologic pathology, it can show only the form, and never
the process at work; only chemistry can give the solution, and he pre-
sents his findings as a beginning in the pathology of metabolism. His
first chapter lays down the principle that metabolism is disturbed by
excess of any constituent in the diet, and if the excess is prolonged, the
disorder becomes permanent; diabetes and gout are examples. In an
analysis of 218 careful case histories, he showed that carbohydrate had
practically always predominated in the diet; but critics must observe
that Cantani practised in Rome. He believed the greater frequency
of the disease in Italy as compared with Germany and Austria to be
due to centuries of over-rich carbohydrate diet. When nervous shock
or other causes seem to bring on diabetes, he thought that the incipient
disease was generally present before. He admitted that a primary
predisposition must precede, because so many persons can live on
excessive carbohydrate diet and never develop diabetes. He con-
sidered the seat of diabetes to be in "the abdominal organs of diges-
tion, the chylopoietic glandular organs" ( (l), p. 363). Atrophy of
the pancreas present in some of his own cases and those in the litera-
ture was interpreted by him as the result and not the cause of diabetes.
He believed (p. 331) that sugar is mostly absorbed through the thoracic

HISTORY 31

duct and only a small portion enters the liver through the portal vein;
and (p. 257) quoting Kiihne's 1868 text-book of physiological chemis-
try against the glycogenic theory, he expressed surprise that a chemist
like Pavy should believe that the liver could change sugar into glyco-
gen. He thought it probable that the blood sugar in health fails to
pass into the urine because burned in the epithelial cells of the kid-
ney.'" Diabetic symptoms were attributed to the non-combustion of
sugar and its circulation in excess. He claimed to show (pp. 274r-275)
that the sugar of diabetic blood is a so called para-glucose, which is
reducing but non-polarizing and non-assimilable; the kidneys trans-
form it and excrete it in the urine as true glucose. He regarded ace-
tone formation and coma as due to the digestive disorder, and as acci-
dental in character. His treatment set an entirely new standard of
strictness; this was the essential contribution made by Cantani. He
isolated patients under lock and key, and allowed them absolutely no
food but lean meat and various fats. In the less severe cases, eggs,
liver, and shell-fish were permitted. For drink the patients received
water, plain or carbonated, and dilute alcohol for those accustomed to
Kquors, the total fluid intake being limited to one and one-half to two
and one-half liters per day. For flavoring were permitted acetic and
citric acids, and distillate of orange blossoms. Lactic acid was given
regularly as the best substitute for carbohydrate and to aid digestion;
Cantani deemed that by means of it he was enabled to keep patients
on a more rigid diet than any of his predecessors. The quantity of
protein was carefully limited; 500 gm. of cooked meat per day were
considered enough for any diabetic, and 300 to 400 gm. sufl&cient to
maintain strength. The value of vigorous muscular exercise was
recognized, and it was proved by clinical tests that glycosuria was thus
diminished or abolished without change in the diet. If the glycosuria
was not otherwise controlled, fast-days were imposed, as often as once
a week if necessary. On these days nothing was allowed but water, or
sometimes bouillon three times a day. The protocols show a sharp
drop in the glycosuria on fast-days.'^ The duration of this treatment

'" This idea has lately been supported by Reicher, by Pierce, and by Woodyatt.

'' Stokvis (1886) considered fast-days as having only experimental interest,
stating that in Cantani 's records, the glycosuria returned promptly in every case
and not one showed any clinical benefit.

32 CHAPTER I

is also a noteworthy step; the regular period was three months, and
it was extended to six or even nine months if necessary to achieve
sugar-freedom. After two months of absence of glycosuria, green
vegetables were begun; and later wine, cheese, nuts, sugar-poor fruits,
and finally small quantities of farinaceous foods were added. Notice
was taken of the different tolerance for different forms of carbohydrate
(p. 230). Glycerol'^ was found to produce a return of glycosuria in
sugar-free patients (p. 258). The urine was analyzed daily during
treatment, afterward once every week, then every two weeks. The
least trace of glycosuria (p. 229) called for one or two months of abso-
lute protein-fat diet. The patient who could return to moderate car-
bohydrate diet was considered genuinely cured. If a more generous
diet brought a return of glycosuria, it was regarded not as a relapse
but as a fresh attack, caused by the same excess in carbohydrate which
produced the diabetes in the first place. This determined insistence
upon sugar-freedom was Cantani's best contribution; but it was
marred by faults which have persisted since, namely, the high calory
fat diet, the beUef (p. 231) that gain in weight is one of the most
important benefits, and (p. 386) that a slight glycosuria is preferable
to undernutrition. Regarding his failures, Cantani believed (p. 356)
that as long as the pancreas alone, or perhaps the stomach alone, is
diseased, the diabetes is curable in all cases, but after the liver is in-
volved a cure is impossible. He acted (pp. 369-370) on the theory of
sparing a weakened organ. He held the modern view that diabetes
is a unit, and that the varying cases represent different degrees or
stages, not different diseases. He distinguished two groups: cases in
which sugar disappears on meat diet, and those in which it does not dis-
appear. He judged that the lowered temperature and the slowed
respiration were evidence of a diminished metabolism in diabetes. He
thought (p. 203) that diabetes is better borne by fat than by thin people
because of their lower metabolism, and that the greater severity of dia-
betes in young persons and children is explained by the higher metab-
olism. The diminution of glycosuria on fasting was held (p. 190)

^^ Glycerol in the treatment of diabetes was first used by Basham {Lancet,
January, 1854). It was especially advocated by Schultzen (Bed. klin. Woch.,
1872, No. 35) on the basis of an erroneous chemical theory. Cf. Naunyn ( (5), p.
441).

msTOEY 33

to prove that the diabetic's own tissues are not convertible into sugar,
though the glycosuria on meat diet shows that sugar can be formed from
ingested protein. The description (p. 302) of a case of cerebral tumor,
causing paralysis of the optic and oculomotor nerves, with poljTiria
and 3 per cent glycosuria, which cleared up after several months, while
the tumor progressed and caused death, may now receive probable
interpretation at the first mention of h5^ophyseal diabetes. The
infectious nature of tuberculosis being unknown, the development of
pulmonary tuberculosis in a diabetic was to Cantani (pp. 113, 233) a
sign that the glycosuria could never be abolished, that the breakdown
in metabolism was hopeless, and death inevitable.

The authors who described gross lesions of the pancreas in diabetic
necropsies are named by Bouchard ( (1), p. 171) as follows: Cawley,
Elliotson, Bright, Bouchardat, Griesinger, Hartsen, Fles, von Reck-
linghausen, von Frerichs,Klebs, Harnack, Kuss, Cantani, Silver, Fried-
reich, Haas, Lecorche, Lancereaux.^' Zimmer in 1867 supposed that
carbohydrates are normally split to lactic acid in the intestine, but in
the absence of pancreatic juice the process stops at the stage of glucose,
with resulting glycosuria; but later he considered diabetes as a defect
of muscular metabolism. Popper (1868) assumed that diabetes is due
to lack of pancreatic juice, causing disturbance in fat digestion and
secondarily in glycogen storage in the liver. Lancereaux, a pupil of
Claude Bernard, described a form of diabetes characterized by sudden
onset, marked emaciation, polyphagia and polydipsia, characteristic
feces, and early death. He correctly interpreted this complex as
evidence of a pancreatic lesion. Hirschfeld later described similar
cases. But Lancereaux and his pupil Lapierre proceeded to assume
that all diabetes with emaciation is due to a gross pancreatic
lesion; to this diabete maigre or pancreatic diabetes they opposed the
type of diabete gras or fat diabetes, supposedly not pancreatic in ori-
gin. They also added later a "constitutional" or "arthritic" diabetes
and a "nervous" diabetes. This classification has been generally dis-
credited but still persists to some extent in France.

Baumel was the first to set up the hypothesis that all diabetes is

''Other literature is given by Sauerbeck, Rosenberger (p. 206), and Allen,
( (1), Chapter 21).

34 CHAPTER I

pancreatic in origin. When no gross or microscopic alterations could
be found, he assumed the presence of a nervous or circulatory disturb-
ance. Lack of pancreatic diastase was imagined to be the essential
factor, and the inhibition of secretion of pancreatic juice by stimula-
tion of the central end of the vagus was considered illustrative of
what might occur in diabetes of functional origin.

Bouchard followed Lancereaux in regarding diabetes with emacia-
tion as pancreatic in source. He upheld the doctrine of diminished
utilization as opposed to Bernard's view of simple overproduction of
sugar, and he classified diabetes among the diseases due to retardation
of metabolism.

Friedrich Theodor von Frerichs (1813-1885) published a work of
careful objective description, free from theories and preconceptions,
based on an experience of 400 cases and 55 necropsies. His preface
' states that he began with the exact science chemistry, passed thence to
physiology, and thence to the clinic, and writes now in the autumn of
life to present the fruits of nearly forty years' experience. The thor-
ough study and analysis of his cases, clinically, chemically, and patho-
logically, constitute the author's chief merit in extending the knowl-
edge of diabetes. He distinguished three forms of sudden diabetic
death; viz., cardiac failure, collapse, and the Kussmaul coma. To-
day it seems probable that all three are manifestations of acidosis.
By clinical experiments he made the acetone intoxication theory im-
probable. Ehrlich, with von Frerichs, investigated the glycogen in
'diabetes, not only post mortem but by liver puncture during life.
Ehrlich likewise discovered the so called glycogenic degeneration of
the renal tubules in diabetes.

Richard Schmitz of Neuenahr was the first to give conclusive dem-
onstration of complete recovery in a few cases of diabetes. Also,
among his 2320 cases he observed 26 in which the diabetes, in ab-
sence of any other discoverable cause, seemed so definitely to come
on after close association with another diabetic (through marriage or
otherwise) as to suggest an infectious transmission. Senator, Oppler
and C. Kiilz, and others have made it reasonably certain that such
cases represent mere coincidence.

Rudolph Eduard Kiilz (1845-1895) was a similar and even more
notable example of a painstaking, unbiased investigator. To him

HISTORY 35

diabetes was a mystery, toward the solution of which theorizing was
futile and only the gathering of the most complete and exact data
possible could be valuable.'^ In journal articles Kiilz published many
laboratory investigations, especially concerning glycogen. Also,
he discovered the oxybutyric acid in diabetic urine simultaneously
with Minkowski, and was first to observe it to be levorotatory. His
clinical experience of twenty-five years covered 1 100 carefully studied
cases of diabetes, of which 711 were chosen for publication. Probably
no other man ever did so much to clarify the subject by proving all
things and holding fast that which was good. His experiments were
the last which finally ended the error of excess of fluid output over
intake in diabetes. He found sugar absent from the sweat. He
showed the uselessness of lactic acid and the harmfulness of glycerol.
He proved the absolutely negative effects of various drugs, notably
sodium bicarbonate and arsenic, for diminishing glycosuria, aside from
the illness and digestive upsets produced; this lesson of KUlz con-
cerning Fowler's solution still needs to be learned by many today.
He demonstrated with exactness that Carlsbad water has no effect
upon diabetes. Although no valid evidence has ever shown that any
kind of water anj^where has specific influence upon diabetes, this
superstition is still so prevalent among both physicians and patients
that diabetics continue to flock by thousands to mineral springs like
pilgrims to medieval shrines. Kiilz disapproved of the methods of
Bouchardat, who jumped at truths without pausing to prove them;
and much of his constructive work actually consisted in establishing
on a substantial basis the suggestions of the brilliant Frenchman. He
tested the tolerance of many patients for many forms of carbohydrate,
finding ( (2), p. 528) that the assimilation is better for green vege-
tables than for the equivalent of starch in other forms; and that lac-
tose, levulose, and even cane sugar are often better borne than glu-
cose, but results are variable and levulose is often harmful and utilized
no better than starch. He was unable to formulate any fixed rule
whether glycosuria is increased by alcohol or not. By careful com-

^* Preface to "Beitrage:" "Main Bestreben ging vor Allem dahin, moglichst
exacte Beobachtungen zu liefern. In wieweit mir dies gelungen ist, in wie weit
diese Untersuchungen geeignet sind, unsere Kenntnisse von diesem in vieler
Beziehung noch so rathselhaften Leiden zu erweitern, mag die Kritik entscheiden."

36 CHAPTER I

parison between periods of days of rest and corresponding periods
with exercise, he reached the conclusion that e!xercise is beneficial in
strong patients with mild diabetes; in severe diabetes, where sugar
is excreted on carbohydrate-free diet, exercise may diminish glyco-
suria, sometimes only transitorily, or it may have no effect; and
in weak individuals with severe diabetes, there was no benefit
from exercise.'^ The great experience of Ktilz was probably the most
powerful factor in establishing the modern view of the unity of dia-
betes. His cases were classified in three groups; first, a mild group,
becoming sugar-free on strict diet; second, a "mixed" or intermediate
group; and third, the group of severe cases, with glycosuria continu-
ing on restricted diet. The numerous careful case records showed
such an abundance of gradations and transitions between these groups,
from the mildest to the most severe, that fixed distinctions between
types of diabetes were shown to be impossible. Kiilz made no use of
undernutrition or fasting. He treated severe cases by gradual with-
drawal of carbohydrate to avoid coma, reduced protein not below 110
gm. daily, and was one of the first to calculate diets according to the
caloric requirement. He was the first to introduce the practice of
systematically testing the carbohydrate tolerance of each patient.
Rumpf" claims as the greatest merit of the Kiilz system the inaugu-
ration of individually planned diets instead of indiscriminating general
rules. Notwithstanding the universal adoption of this plan by special-
ists and the better informed physicians, it is a regrettable fact that
the majority of the profession have not yet come up to the standard of
Kiilz, and the majority of diabetics still receive treatment by means of
printed hsts of "allowed" and "forbidden" foods. Kulz founded a
numerous and influential school. Of the three editors of his posthu-
mous work, Aldehoff is known for various clinical and experimental
studies, Sandmeyer chiefly for the diabetes produced in dogs by pan-
creatic atrophy, and Rumpf as a prominent clinician, who made early
studies of dextrose-nitrogen ratios in human patients (1, 2, 3), and

^' This was not only the most thorough investigation of exercise in human dia-
betes, but also an important independent discovery, for Kiilz did not know of any
previous use of exercise till after completion of his experiments.

'« Preface to Kiilz (2).

HISTORY 37

first (3) warned against loss of body fluid as an important factor in
bringing on coma.

Joseph Friedrich von Mering (1849-1908) was trained under von
Frerichs and Hoppe-Seyler. Though a clinician of high standing, his
fame rests upon his numerous experimental works, among which may
be mentioned his metabolism studies with Zuntz, the discovery (1886)
of phloridzin glycosuria, and the discovery with Minkowski (1889)
of pancreatic diabetes in dogs.

Bernhard Naunyn (born 1839) was the pupil of Lieberkiihn, Reich-
ert, and von Frerichs. Though the author of a number of researches,
they include no important discovery. His position as the foremost
diabetic authority of the time rests upon his influence for the advance-
ment of both clinical and experimental knowledge; upon his judgment,
his teaching, and his pupils; upon the fact that from his great Strass-
burg school have come the soundest theories, the most fruitful inves-
tigations, and the most effective treatment. In birth, it is to be noted
that Naunyn preceded Kiilz, and was only two years younger than
Cantani. He came into this field in the pioneer period when the
principle of dietetic management was generally recognized, but the
average practice, especially in regard to severe cases, was still a mass
1 of ignorance and inefficiency. As late as 1886, Naunyn (1) stood as
the champion of strict carbohydrate-free diet in a German medical
congress where most of the speakers opposed it. As one of the few
early German followers of the Cantani system, he maintained its
feasibility and ultimate benefit, and locked patients in their rooms for
five months when necessary for sugar-freedom. With experience, he
gradually introduced modifications, until the rigid and inhuman
method, which a majority of physicians and patients would never
adopt, became a rational individualized treatment, with a diet reckoned
according to the tolerance and caloric requirements of each patient.
The work of various pupils requires mention in this connection. Im-
portant investigations of metabolism established the basis for this
treatment, the inost notable being that of Weintraud, who proved that,
instead of having an increased food requirement, diabetics could main-
tain equilibrium of weight and nitrogen on a diet as low as or a little
lower than the normal. Minkowski discovered with von Mering the

38 CHAPTER I

diabetes following total pancreatectomy in dogs," and established
the doctrine of the internal secretion of the pancreas, as well as the
first clear conception of a dextrose-nitrogen ratio. After the early
acetone investigations and Gerhardt's discovery of the ferric chloride
reaction had failed to reveal the cause of coma, the Naunyn school
accomplished almost the entire development of the subject of clinical
acidosis in the following sequence. Hallervorden (1880) discovered
the high ammonia excretion, confirming an earlier discredited observa-
ton of Boussingault. Stadelmann (1883) established the presence in
the urine of considerable quantities of a non-volatile acid supposed to
be a-crotonic, correlated the condition with Walter's previous acid
intoxication experiments, and theoretically suggested the treatment
with intravenous alkali infusions. Minkowski proved the excreted
acid to be /S-oxybutyric, and demonstrated the presence of this acid
in the blood and a diminished carbon dioxide content of the blood.
He, also Naunyn and Magnus-Levy, applied the alkali therapy in
practice, and the latter carried out chemical and metabolism studies
which made him the recognized authority in this field. Naunyn intro-
duced the word acidosis, saying in definition ( (4), p. 15): "With this
name I designate the formation of /8-oxybutyric acid in metabolism."
The Naunyn school have consistently maintained that this acidosis
is an acid intoxication in the sense of Walter's experiments. They
demonstrated striking temporary benefits from the alkali therapy,
particularly in diminishing the danger of the change from mixed to
carbohydrate-free diet; but the practical results were never equal to
the theoretical expectations. With Naunyn, also, acidosis became
the principal criterion of severity for the clinical classification of cases.
As regards other theories, the Naunyn school have upheld the deficient
utilization as opposed to the simple overproduction of sugar in dia-
betes. They have clearly recognized the necessary distinction be-

" This is commonly supposed to have been an intentional following up of the
observations of Cawley, Bouchardat, and others. But according to Dr. A. E.
Taylor (personal conmumication) the epoch-making discovery was accidental.
Dogs depancreatized for another purpose were in a courtyard with other dogs.
Naunyn, perhaps mindful of the part played by insects in the history of diabetes,
asked, "Have you tested the urine for sugar?" "No." "Doit. For where these
dogs pass urine, the flies settle."

HISTORY 39

tween diabetes and non-diabetic glycosurias." Naunyn was next
after Klemperer to recognize clinical renal glycosuria. Though
observing that "the course of the disease is as variable as can be
conceived," he nevertheless upholds the essential unity of diabetes,
finding in heredity a link which often connects cases of the most varied
types. In regard to the etiology, he considers that "it is certain that
disease of. the nervous system and of the pancreas can produce dia-
betes;" other causes seem more doubtful. The nervous disorder
supposedly acts indirectly by setting up a functional disturbance in
the pancreas or other organs directly concerned. Underlying every-;
thing in most cases is, in his opinion, the diabetic "Anlage" or inherited;
constitutional predisposition. Naunyn has particularly supported;
the conception of diabetes as a functional deficiency, to be treated by
sparing the weakened function. He wisely emphasized the impor-
tance ( (5), p. 391) of doing this at as early a stage as possible, before
the tolerance has been damaged and the glycosuria has become "ha-
bitual." His plan of treatment is to withdraw carbohydrate gradually,
giving large doses of sodium bicarbonate in cases with acidosis as ii,
further precaution against coma. A brief increase of the ferric chloride ;
reaction is not allowed to interfere with the program. When the
glycosuria is successfully cleared up, the aim ( (5), p. 396) is if possible
to place the patient on a Rubner diet, representing 35 to 40 calories ;
per kilogram of body weight and about 125 gm. protein (pp. 407-.
408), carbohydrate being gradually (p. 415) added and then kept (p.,
416) at a figure safely below the tested tolerance. The views con-,
cerning exercise (p. 432) agree with those of previous authors; brisk
walking, etc., is found beneficial; but overexertion is harmful, especi-
ally in severe cases; and some patients seem to do best on a rest cure.
When sugar-freedom is not attained on simple withdrawal of carbo-
hydrate, protein may be reduced as low as 40 to 50 gm. daily ( (4), p.
22) and the calories also diminished, since ( (4), p. 22; (5), p. 397)

''Magnus-Levy {(2), p. 8), concerning pancreas-diabetes: "Dieser Diabetes
ist der einzige experimentelle, der tatsachlich als Diabetes zu bezeichnen ist."
Naunyn ( (2), p. 3130) : "Einen Diabetes melitus haben die Experimentatoren vor
Minkowski und von Mering nie erzeugt . D er sogenannte Kurare, der Kohlenoxyd,
etc., der Stichdiabetes und selbst der Meringsche Phloridzindiabetes, sie alle tra-
gen diesen Namen mit Unrecht."

40 CHAPTER I

diabetics may remain in equilibrium on as little as 25 to 30 calories
per kilogram. When necessary as a final resort, temporary under-
nutrition may be employed ( (S), pp. 392, 409) ; but prolonged under-
nutrition or the loss of more than 2 kilos weight should be avoided
( (4), p. 15). Loss of weight continuing over the third week of treat-
ment requires adding carbohydrate and abandoning the attempt to
stop glycosuria ( (5), p. 414). Occasional fast-days are advised if
necessary ( (5), p. 409), but only when previous treatment has reduced
the glycosuria below 1 per cent; otherwise their effect is indecisive
( (5), p. 426). It is stated ( (5), p. 425) that such fast-days are prac-
ticable for even the severest cases, and heavy acidosis is not a contra-
indication (p. 426); the ferric chloride reaction may diminish on a
fast-day (p. 414). Naunyn has not stated what hmitations apply to
the use of such occasional fast-days, but Magnus-Levy ( (2), p. 67)
stipulates that they must never be more frequent than one in eight or
ten days, and in very thin patients must be avoided altogether. Fast-
ing is nowhere recommended as a treatment for coma by Naunyn.
On the contrary, when restriction of diet produces really threatening
symptoms, his plan is to add carbohydrate and give up the attempt to
abolish glycosuria '( (2), p. 3144; (5), p. 414). Even the persistence
of a very heavy ferric chloride reaction longer than two or three days
is a signal for adding carbohydrate (p. 425). The treatment for im-
pending coma consists in maximal doses of bicarbonate and the free
use of carbohydrates, especially milk ( (4), p. 28; (5), pp. 350, 351;
also Magnus-Levy, (2), p. 77). Naunyn had some conception of
limiting the total metaboUsm ( (4), p. 14), but meant by it only a bare
maintenance diet, or the sUght and temporary undernutrition men-
tioned above. Naunyn ( (4), p. 13) states that fat does not appreci-
ably increase glycosuria; elsewhere ( (6), p. 741) that in very severe
cases it may slightly increase glycosuria; Magnus-Levy ( (2), p. 21)
that it never gives rise to glycosuria. Like others, Naunyn considers
that fat is the chief food for the diabetic ( (5), p. 449) ; that the intro-
duction of fat is the most important art in diabetic cookery ( (6) , p. 741) .
He uses it to complete the full number of calories when other foods
are restricted ( (5), pp. 408, 447); this apphes even to the severest
cases on carbohydrate-free diet with strict limitation of protein, where
accordingly much fat is given (p. 424) ; his principal care is that the

HISTORY 41

patient shall take enough of it (p. 395) ; the only reason for limiting
the quantity is the danger of indigestion (pp. 395, 424), except when
coma impends, in which case fats are replaced by carbohydrates, and
butter is especially shunned because of its content of lower fatty,
acids (p. 350). Even when sugar-freedom is attainable, certain cases
are believed to show an inherent progressive downward tendency
( (2), pp. 3135-3136; (5), p. 390). Concerning patients emaciated
down to 50 kilograms, with heavy ferric chloride reaction and the
usual accompaniments, it is said (p. 425) : "In the face of these great
difficulties and dangers, which accompany the energetic management
of these very severe cases, the prospects of being successful in per-
manently removing glycosuria are in general not very great, and usually
one will be content with a limitation of it which suffices to bring the
patient into nutritive equilibrium, that is, down to 60 to 80 gm. sugar
in 24 hours."

Lenne of Neuenahr is known chiefly for his advocacy of low
protein diet. His plan is to reduce the nitrogen intake until the out-
put falls to his so called "normal" figure; viz., 0.37 gm. urea or 1.1 gm.
absorbed protein per kilogram of body weight (about 1.3 gm. per kilo
in the diet). Carbohydrate is also limited, but the protein restriction
is considered more important. He classifies cases into four groups:
those in which (1) the glycosuria ceases on diminution of protein
without diminution of carbohydrate and the protein requirement
falls to 1.1 gm. per kilo; (2) this result is achieved only by reducing
carbohydrate as well as protein ; (3) limitation of protein and carbo-
hydrate stops glycosuria but the protein requirement never falls to
1.1 gm. per kilo; (4) glycosuria continues and nitrogen remains high
in spite of complete withdrawal of carbohydrate and strict limitation
of protein. He believes in simple overproduction of sugar without
impairment of utilization as the explanation of diabetes, and in the
correlated doctrine of sugar formation from fat. He states ( (1), p.
82) that it is not necessary to assign any upper limit for fat, since
appetite and digestion set the limit; later (2) he speaks in favor of
fat restriction, but only in the sense that the diet should be adequate
but not excessive. He does not limit fat even for the sake of acidosis,
since he disbelieves in the acid intoxication theory of coma, and cites
( (3), pp. 252-253) the example of a patient whose urine became free

42 CHAPTER I

from diacetic acid on carbohydrate abstinence, insufficient protein,
and excess of fat. He insists on abolishing glycosuria and hyper-
glycemia if possible, and opposes ( (l), p. 74) von Noorden's opinion
that some diabetics, especially the elderly, can be indulged in eating
as long as sugar is liot excreted above 20 gm. daily. Nevertheless he
refuses (p. 83) to prolong absolute carbohydrate-free diet for a week or
over. For stubborn glycosuria he has used fast-days, but prefers to
avoid any complete abstinence. His protocols show the benefits of
protein reduction, but also indicate the failure of the method in numer-
ous cases of only moderate severity.

It is desirable at this point to introduce a digression, for the purpose
of considering the so called "carbohydrate cures" as a group.

It will be observed that carbohydrate has been the touchstone of diabetic
therapy since the time of Rollo. All the orthodox theories have agreed in holding
it as the one offending substance, and a large proportion of physicians today still
conceive of dietotherapy as limited to prescribing a list of carbohydrate-poor
foods. On the other hand, the vast majority of diabetic patients have (following
or defying advice) never undergone rigid deprivation of carbohydrate for any long
time, the specialists of highest repute have granted it in the later stages of the more
severe cases, and there has grown up a line of treatment characterized by diets
heavy in carbohydrate.

The milk diet is historically first. According to Stokvis, milk was recommended
for diabetes by almost all authors in the eighteenth century. The Karell cure, pub-
lished in 1866 and still well known in the treatment of obesity and other conditions,
was a diet limited strictly to 60 to 200 cc. of skim milk four times daily. Rich-
ardson credits "Dr. Smart of Edinburgh" with priority in the use of a formal
"milk cure" in diabetes. A skim milk treatment was advocated by Donkin (1869)
on the claim that it was pleasanter than the Bouchardat plan and also more effec-
tive, as casein is better assimilated than other proteins, and lactose than other
forms of carbohydrate. Balfour, Oettinger, Winternitz and Strasser, Maurel,
Landouzy and Cottet, and numerous others championed the milk treatment, but
Kiilz, von Frerichs, and most authorities condemned it. Strasser advised three
days of milk, then three days of strict diet, and so on alternately — a schedule
which might rank high among carbohydrate "cures."

Prasad asserts that in India a diet chiefly of milk permits mildly diabetic patients
to live fifteen or twenty years. Naunyn considers that it is hard to get along with-
out milk in treating diabetes, and that milk "cures" are often beneficial. He and
his followers have used it as the principal means to ward off acidosis. Guelpa's
use of milk is mentioned later. Recently (1915) Farges has taken up the original
belief concerning milk, holding that not only is lactose perfectly assimilated in mild
diabetes, but that it actually improves the tolerance for other carbohydrates.

HISTORY 43

Sour milk and its commercial preparations have been used to some extent, but
according to von Noorden ( (1), p. 315) only 10 to IS per cent of the sugar is de-
stroyed in the natural curdling, and souring beyond this point makes the taste too
unpleasant for use; he therefore rates sour milk as neither bettfer nor worse than
sweet milk. The status of the typical milk cure as a form of undernutrition treat-
ment is universally recognized.

Second chronologically was the treatment of von During of Amsterdam, often
incorrectly styled the "rice cure." The first edition of this author's book appeared
in 1868, the fifth edition in 1905. He limited his patients to three or four meals
daUy, representing a total of 80 to 120 gm. of any cereal (frequently rice, least often
oatmeal because of its tendency to ferment), up to 250 gm. meat, moderate quan-
tities of stewed fruits, and small allowances of stale bread, milk, and wine. His
general position was a protest against overeating and luxurious living, and a "back
to nature" attempt in food, exercise, and general hygiene. He was a pioneer in
sanitarium discipline and restriction of the total diet. One interesting trick was
his use of ice and ice-water to combat polyphagia. He was a zealot in his beliefs,
but frankly acknowledged numerous failures. His method may be interpreted as
a mixed ration rather low in protein and calories, not infrequently proving prefer-
able to the protein-fat excess of which his earlier contemporaries were signally
guilty.

Dujardin-Beaumetz (1889) first recommended potatoes for diabetics in quanti-
ties below 100 gm., because they contained less carbohydrate than the usual gluten
bread. Mosse (first publication 1898) believed potatoes to be far superior to other
forms of carbohydrate for assimilation in diabetes, and attributed the supposed
virtue to their content of potassium, and perhaps also of organic acids, traces of
manganese, or oxidases. He gave as much as 1500 gm., or in polyphagia 3000
gm., not as occasional "cures" but as regular additions to the daily diet. His
records and graphic charts of comparisons between potatoes and bread reveal in
many instances a much smaller quantity of carbohydrate in the potato diets; in
other cases the quantity of carbohydrate was kept equal, but it is doubtful if
patients taking such large quantities of potatoes would eat as much of other kinds
of food as when taking bread. The alleged advantage of potatoes is thus readily
explained. Also the treatment was very bad throughout, for though the cases were
mild, there was no pretense of stopping glycosuria, which was high even in the cases
showing the imagined benefit. The treatment thus poorly founded gained wide-
spread adoption only in France. Rathery refers to the numerous patients there
who complain of glycosuria uncontrollable by strict diet, when inquiry shows that
they are consuming potatoes liberally in the belief that they are harmless and
beneficial. He finds it necessary to point out the smaller percentage of starch in
them as compared with bread or cereals. Labbe, by testing a series of mildly
diabetic patients with allowances slightly above their tolerance, composed a list of
carbohydrates in descending order of assimilation, as follows: potato, oatmeal,
macaroni, chestnuts, rice, beans, lentils, peas, milk, bread, sugars. Linossier,

44 CHAPTER I

discussing certain of these papers, properly called attention to the lower protein
and calories of the potato diets. The facts concerning potatoes are fully explained
by their relatively low food value, in that they carry little protein or fat and only a
fraction of the carbohydrate percentage of bread or cereals, while their bulkiness
tends to diminish the consumption of other foods. They are a higher homologue
of the green vegetables, and may be used correspondingly in the milder grades of
diabetes.

Von Noorden made the chance observation that certain patients showed marked
improvement in their diabetes, even to cessation of glycosuria, when placed be-
cause of digestive disturbances on a diet of oatmeal gruel. It is probable that such
rations were rather low in protein and calories. In 1902 he announced his formal
"oat-cure." Though there were ahready facts in the literature to indicate the true,
explanation, the diminution or disappearance of glycosuria on change from strict
to carbohydrate-rich diet impressed von Noorden and the contemporary medical
World as an astounding and mysterious phenomenon. Naunyn held a skeptical
attitude throughout . He favored the untenable hypothesis of intestinal fermenta-
tion supported by his pupil Lipetz, but he also (4A) early classed all carbohydrate
"cures" together and declared that the essential benefit lay in undernutrition.
Kolisch's correct suggestion of the importance of a low .protein intake was sup-
posedly disproved by the incorporation of eggs and vegetable protein in the oat
diet. Falta and others employed smaller quantities than the established 250 gm.
of oatmeal; but none perceived that the value of the "cure" diminished as the
quantities of foods were increased. The therapeutic endeavor was to make up a
full Voit diet to avoid undernutrition, depending on the supposed virtues of oat-
meal and special proteins to achieve assimilation. DiflFerences in the manner of
cooking, and even distinctions between brands of oatmeal, were asserted and ac-
cepted. The experimental goal was to discover the reason for the superiority of
oatmeal over other carbohydrates, and thus much fruitless labor was spent upon
oat extracts, digestion, renal permeability, and intestinal bacteriology. Thus the
entire clinical and experimental development of von Noorden's primary observa-
tion followed mistaken lines. Blum in 1911 attacked the foundation of the error,
by comparative tests showing the equal assimilation of oatmeal and other carbo-
hydrates when administered to diabetic patients imder identical conditions. He
likewise overthrew the perplexing claim that the severe cases are the ones that
assimilate oatmeal best; and it is now generally recognized (cf. Magnus-Levy (2),
p. 70) that cases doing well on carbohydrate "cures" are essentially mild even
though they may have appeared severe. Also in 1911, Klemperer showed that
even sugar behaves similarly when given in divided doses. The von Noorden
school has maintained, with diminishing force, that oatmeal possesses some degree
of superiority, and has arranged a scale of assimilability, in which bananas and
barley stand next to oatmeal, and wheat and rice are at the lower end. The litera-
ture up to 1913 permitted no positive conclusion. Minkowski (4) , in a sweeping crit-
icism of the Vienna doctrines, acknowledged the benefits of the oat cure. Magnus-

HISTORY 45

Levy added his experience in support of the relatively better assimilation of oat
starch. It has since become clear that the mixed or indecisive clinical observations
of von Noorden, Lampe," Werbitzki, Piskator, Richartz, Weiland, and other
authors previously referred to furnish no sound evidence of any peculiar assimila-
bility of oatmeal. On the contrary, accurate.comparative tests by Petersen, Wolff,
and Falta have fuUy confirmed Blum's position. Jastrowitz found complete simi-
larity between oats and wheat in experiments on totally and partially depan-
creatized dogs. Csonka lately proved the equal and complete elimination of the
carbohydrate of wheat and oats as glucose by phloridzinized dogs. The absence
of any specific ease of assimilation of oatmeal by human patients has been demon-
strated in the blood sugar investigations of Schirokauer, Severin, Lamp6 and
Strassner, Wolf and Gutmann, and Menke, and in the studies of respiratory
metabolism by Schilling, Roily, Roth, Joslin (2), and Allen and DuBois.

The buckwheat (Alvord), raisin, and other sporadic "cures" require no special
discussion. All the early carbohydrate treatments laid stress on the restriction to
only one form of starch, but the benefit of such limitation was always incompre-
hensible and is now recognized as imaginary. The later recommendations offer
greater variety. Labbe has introduced a "dry legume cure," with a diet of 300
gm. beans (including lima, soy, or other varieties), peas, or lentils, 150 gm. butter,
3 to 6 eggs, 3 to 6 aleuronat or gluten cakes, green vegetables, and wine. The
main thing avoided is meat. Falta, having renounced his old allegiance, now
uses "mixed cures" planned after the oat cure except that monotony is avoided by
means of alternation of all sorts of carbohydrate foods, with addition of green
vegetables.

The rationale of the carbohydrate "cures" appeared mysterious when diabetes
was regarded as a deficiency of carbohydrate assimilation, but becomes clear with
the imderstanding of diabetes as a general disorder of nutrition. Most of the diets
represented some degree of undernutrition. In the oat cure, this was attained by
the preceding and following vegetable or fast-days, adopted from Bouchardat,
Cantani, and Naunyn. Temporary relief from the overload of protein and fat
diet was afforded by the substitution of an excess of carbohydrate. The experi-
ence showed that the latter is, at least for short periods, often less injurious and
dangerous than the former. The successful results demonstrated the surprisingly
high tolerance still retained in a large proportion of diabetic cases heretofore
classed as severe. The invariable failure encountered in truly severe cases fol-
lows as a simple corollary to the defim'tion, since the nature of severe diabetes
involves inability to metabolize such quantities of carbohydrate, protein, and fat.

Aside from the carbohydrate "cures," there have long been practi-
tioners of higher and lower degree who have upheld the opposite
of Rollo's animal diet, namely, a pure vegetarian diet. Harley em-
ployed it for cases of a certain type. Kolisch may be mentioned as
the principal champion of this system. He argues that diabetes does

46 CHAPTER I

not consist in a lowered tolerance for carbohydrate, because a small
quantity of carbohydrate often causes less glycosuria than a large
quantity of protein. He regards the disorder as an overproduction of
sugar, derived from unknown compounds in the tissues. The improve-
ment of tolerance on carbohydrate-free diet, also the cessation of
glycosuria in cachexia observed by Cantani and Naunyn, are explained
as due to impoverishment in sugar-forming material. Food, especially
protein, is supposed to irritate the tissues so as to stimulate sugar
formation. Therefore the author reiterates Bouchardat's advice,
"manger le moins possible," and particularly restricts protein. He
regards fat as the food which sets up the least stimulus to sugar for-
mation and which never gives rise to glycosuria ( (1), p. 248). He
enforces vegetarianism, because patients are thus kept in equilibrium
on 20 to 25 calories per kilogram of weight with a diet bulky enough to
satisfy, and because he believes that this maintenance requirement is
lower than on animal food, that vegetable protein has a superiority
over animal protein in contradiction to the caloric theory, and that the
vegetable diet is intrinsically less irritating to the diabetic process.
Milk is regarded as somewhat similar. Fast-days are supposed to
benefit through absence of food irritation, but they are held ( (1), p.
252, and elsewhere) to have little practical value, because their effect
is transitory and glycosuria always returns. Kolisch (2) makes a
trenchant criticism of the Kulz method of testing tolerance, objecting
that this shows merely the result of adding relatively small quantities
of carbohydrate to large quantities of protein and fat. Instead, he
advocates trying various combinations of foods, and choosing the one
which permits maintenance on the lowest number of calories, also the
taking of as much carbohydrate as possible without harm. Here a
critic will necessarily ask for a definition of the phrase "without harm."
Von Noorden ( (1), pp. 369, 372) calls attention to the phenomenon
studied by Leo, Rosenfeld, and Kolisch, that up to a certain point
many diabetics assimilate more carbohydrate as the quantity ingested
is increased (paradoxical law) ; the practice of giving such a ration as
will cause the greatest possible combustion of carbohydrate is called
the method of Rosenfeld and Kolisch; von Noorden opposes this
method for mild or moderate cases, but endorses it for severe cases.
Roubitschek and Gaupp are among the recent advocates of this "best

HISTORY 47

oxidation level" program, naming Klotz also in support of it. This is
one phase of the method of the so called "carbohydrate balance," under
which physicians everjrwhere have been greatly concerned over the
relation between the quantity of carbohydrate ingested and the quan-
tity of sugar excreted, and, especially in threatening acidosis, have
juggled the diet in every possible way to make the former greater than
the latter. The method has also been used very widely and by the
highest authorities for the sake of mere comfort and temporary well-
being of the patients; for example, von Noorden's advice, criticized
above by Lenne; the advice of Naunyn ( (4), p. 20) that not more
than 0.5 per cent glycosuria is allowable in mild cases; and the state-
ment of Magnus-Levy ( (2), p. 67) that the advantage of 100 gm.
bread in the diet is worth the excretion of 20 or 25 gm. sugar as long as
no complications are present. This entire method is fundamentally
vicious and in the end defeats every purpose for which it is employed.
On the other hand, there is interest in the view of Kolisch, similar to
that of Lenne, that the patients with milder diabetes are injured by
heavy protein-fat diet, even though glycosuria and other s3anptoms
are absent; and that the ultimate consequence is that they progress
downward and later show the severe form. For such cases Kolisch
.favors a low calory mixed diet, containing little meat and plenty of
vegetables, with carbohydrate in quantity just short of producing
glycosuria.

Albu is the author of the most recent vegetarian system for
diabetics.

Carl Hanko von Noorden has occupied a position of eminence among
diabetic specialists in the generation after Naunyn. He was trained
under Hensen, Riegel, and Gerhardt, has directed important clinics at
Frankfort and Vienna, and by his writings has done much to diffuse
knowledge of the rational treatment of diabetes. The investigations
of his large and influential school are voluminous, but belong
mostly to the theoretical side of the subject. He long maintained the
deficient utilization of carbohydrate in diabetes, but in the later edi-
tions of his text-book went over to the pure overproduction h)rpothesis.
He also supported the polyglandular doctrine, which assails the unity
of diabetes; but, though still nominally defending it, and assigning
great importance to the liver and the thyroid, his later writings con-

48 CHAPTER I

cede the essential contentions of his opponents ((2), p. 69): "But
really these differentiations do not shake the essential unity of the
metabolic disturbance in diabetes in the very least. I think I shall
be voicing the opinion of all pathologists when I say that every indi-
vidual who has a diminished tolerance for carbohydrate, either per-
manently, or extending at least over a considerable period) and thus-
exhibits the most important clinical symptom of diabetes, must be
considered as a subject of pancreatic insufficiency. We need not
always expect to find perceptible anatomical evidence, for there may be
functional impairment where no macroscopic or microscopic patho-
logical appearances can be discovered." Von Noorden has been un-
fortunate in his support of false theories, but he deserves credit as the
principal upholder against the Naunyn school of two doctrines which
now appear to be justified by facts : first, that diabetic acidosis repre-
sents something more than lack of carbohydrate; second, that the
symptoms of acidosis, including the fatal termination, are due to some-
thing more than simple acid intoxication. Von Noorden's clinical
work has consisted chiefly in systematizing and improving the Kiilz;
method in some details. He justifies the Kiilz treatment by the state-
ment that he has under his care some of Kiilz's patients who have re-
mained in good condition for seventeen years. The one distinctive
feature introduced by von Noorden, the oat cure, was previously-
discussed. Though he stands as the most prominent believer in the
formation of sugar from fat, this belief has not influenced his treat-
ment; for he "perhaps gives diabetics greater quantities of fat than-
anybody else;" he regards fat as the anchor of their salvation; he has.
almost never seen increase of glycosuria from it, except when digestive
upsets occur, in which many diabetics immediately excrete more
sugar ( (1), p. 96). Nevertheless he recognizes occasional "fat-sen-
sitive" cases. High fat intake, greatly in excess of the requirement,
is said to increase metabolism, like every overabxmdant diet, and'
therewith increases the sugar excretion. But in order to produce this^
increase of glycosuria, the quantities of fat required are so high as to-
be superfluous and of no practical importance in treatment. In the
presence of severe acidosis, it is held that butter should be avoided,
but that ordinary animal and vegetable fats cause no increase of
ketonuria in a patient accustomed to strict diet ( (1), p. 141), and even*

HISTORY 49

during the transition to strict diet the administration of alkali is an
adequate precaution (p. 293), so that fats are given freely even under
these circumstances. In addition to alkali, von Noorden formerly-
treated impending coma with carbohydrates, especially oatmeal, milk,
and levulose; but recently he has found that one or two fast-days are .
far more effective. On these days the only food is alcohol in large
doses, up to 200 to 250 cc. cognac. As soon as the glycosuria and aci- .
dosis are thus partially controlled, he hastens to inflict an oat cure
( (1), p. 388). Here also the fat intake is limited, thus contradicting
his previous contention. A large proportion of severe cases are con-
ceded to be hopeless ; here a liberal varied diet is allowed, the glyco-
suria being merely limited and the strength maintained ( (1), p. 371;
(2), p. 151) and 15 to 20 gm. sodium bicarbonate and about 6 gm.
calcium carbonate given daily for the acidosis ( (l), p. 389) . Not only
strict diet or vegetable days, but also actual fast-days, are interposed
in this program. ( (2), p. 93) : "There are but few diabetics who do not-
become sugar-free on these days,^' and you will at the same time notice
an enormous fall in the acetonuria. Fast-days, combined with bed
rest, are excellently borne. I never find that the patient's strength
is unduly diminished by them. An important result is regu-
larly attained in the immediate and well-marked rise of tolerance
which follows." Again ( (2), p. 152) : "We need have no fears that the :
hunger day will damage seriously the general nutrition. Of course the
body weight falls on the fast-day, but the loss is rapidly made up, and
by this combined method we often obtain considerable increases in
weight." Von Noorden refers to these fast-days as "metabolic Sun-
days." The metaphor is striking and accurate, but the insufficiency
of the metabolic rest and the attempt to build up weight in the pres-
ence of glycosuria and acidosis are fatal to the patients and to the
method.

Weichselbaum and Stangl in 1901 first observed the specific "hy-
dropic" degeneration of the islands of Langerhans. It is remarkable
that one of the most important contributions to the morphologic

" Remarks of this sort show the actual mildness of many cases classified by
writers as severe.

50 CHAPTER I

pathology of diabetes should have met with such a complete lack of
confirmation or credence.

Among English writers, Williamson in 1898 published a text-Hook
possessing permanent value by reason of the author's great experience
and wide knowledge. Recently (2) he has made some use of a diet
consisting only of casein and cream given in small quantities every
two hours. He attributes the benefit to this latter device and to the
reduction in the total quantity of food, but says: "In the most severe
forms of diabetes with marked diacetic reaction in the urine, I do not
at present feel justified in recommending the casein treatment."

Cammidge ( (1), p. 297) held that with impaired fat metabolism in-
dicated by wasting, lipemia, and acetonuria, a limitation of fat in the
diet and its partial replacement by carbohydrate is advisable, even
though glycosuria be increased. More recently (2) he has advocated
a treatment resembling that of Lenne. He aptly remarks that fat
and protein metaboHsm should be considered as well as that of sugar,
and that the absence of any striking color reaction for protein disturb-
ance, comparable to those for detecting sugar or diacetic acid, goes far
to account for the neglect concerning the protein metabolism. The
treatment consists in reduction of protein, rest in bed, and opium when
nitrogenous equilibrium cannot be established by any other means.
In adopting recently the fasting treatment, he has emphasized the
study of the protein metabolism for judging the condition and progress.

Modern France has not lived up to Bernard and Bouchardat in this
field. Not only has it remained relatively barren of important origi-
nal contributions, but also, outside the practice of a few specialists,
the knowledge and management of diabetes seem to fall below the high
general standard of French medicine. A French physician on a
recent visit to America remarked that patients in France were less
willing than those in other countries to adhere to restricted diet, and
demanded a cure which would enable them to eat freely.

Lepine has published a very large number of studies especially
concerning blood sugar and glycolysis, but his comprehensive text-
book alters nothing in the accepted treatment of diabetes. The
same is true of his recent review of the therapy (2, 3).

Fasting has been employed in diabetes not only by specialists in

HISTORY 51

this subject, but also by enthusiasts who advocate it as a panacea.*'
Of these the most prominent is Guelpa of Paris. Starting from
an incorrect observation of Dujardin-Beaumetz in typhoid fever,
"that the more regular and rapid the patient's loss of weight, up
to the disappearance of the pyrexia, the quicker and more favor-
able was his course to recovery," Guelpa applied the principle first
to infections. "I have found it an invariable rule that, in febrile
affections, the more promptly emaciation sets in, and the more defi-
nitely it establishes itself, the more sure and rapid is the patient's
progress toward recovery. Conversely, when the patient fails to
exhibit an emaciation proportional to the intensity of his pyrexia, the
illness is always graver and of longer duration, and the convalescence
more prolonged and more interrupted. All this, it seemed to me,
proved, so to speak, mathematically, that disease is a state determined
and kept up by the presence within the body of a quantity of products
of fermentations-toxins and the debris of poisoned tissues — which the
organism must eliminate before it can return to a condition of health."
Having set up the theory of autointoxication as the dominant feature
in all disease, Guelpa proposed fasting — ^generally in three-day periods
— as the sovereign remedy. Symptoms of weakness, headache, and
malaise during fasting, and the sensation of hunger itself, were at-
tributed to autointoxication; food relieves the symptoms by com-
bining with the toxin, while purgation also relieves by sweeping out
the toxin; copious purgation — a bottle of hot Hunyadi-Jdnos water
daily — was accordingly added to the treatment. Among the condi-
tions for which the fasting-purgation treatment is recommended, with
confirmatory histories of grateful patients, are gout and rheumatic
troubles, anemia, bronchitis and asthma, herpes zoster, eczema and
other dermatoses, various ophthalmic conditions, some gynecological
conditions (including postpartum hemorrhage), digestive complaints,
nervous disorders, insanity, epilepsy, drug addictions, various infec-

'"' Some of these are outside the ranks of the medical profession. Hereward
Carrington, in his book, "VitaKty, Fasting and Nutrition," New York, 1908, p.
187, mentions a patient with incipient diabetes who fasted twenty days continu-
ously, becoming free from glycosuria and remaining so for two months thereafter,
when he was lost from observation. In the same place is a reference to a previous
example recorded by C. C. Haskell.

52 CHAPTER I

tions, postoperative complications, etc. Important in the list is dia-
betes, where alone the results have attracted widespread notice. A
diabetic is given the usual fasting and purgation for three to five days.
Other features of the treatment are best shown in Guelpa's own words
((5), p. 131):

"It is necessary to insist on the absolute necessity of repeating the cure from time
to time, and of imposing, during the intervals, which should be carefully lengthened,
a carefully restricted diet. As regards the latter, it is my custom to complete the
first period of the cure (three or four days) by a week of mUk diet, the amount of
milk taken daily not to exceed 2J pints. At the end of this week, however satis-
factory the condition of the patient, I prescribe a second period of cure (three or
four days) to be followed by a week or a fortnight of a regime mainly of vege-
tables, which satisfies the patient by fiUing his stomach, but, in reality, under-feeds
him, the object being to continue the process of forcing the organism to live par-
tially on its reserves and to bum off its debris. The following is a menu of the
diet I generally adopt: Breakfast, coffee or tea without milk; Lunch, clear soup,
salad, one or two apples or pears; Dinner, as lunch. As drink, tea or other non-
nutritive drinks ad lib. In certain special conditions I allow an ounce or so of
bread, or a diet of cooked vegetables. I increase the amount of food after each
repetition of the cure, taking as my guide an analysis of the urine. Since I adop-
ted this regime, I have obtained more rapid and stable cures, without discouraging
relapses. I wish also to draw attention to what I believe to be a deplorable error;
namely, the doctrine that milk is very harmful in the treatment of diabetes. This
is a mistaken view, based on a false interpretation of a single fact. It is quite true
that diabetics kept on milk diet almost always pass an increased quantity of sugar.
This increased excretion, is, however, only temporary. From the fact of the in-
creased glycosuria, the conclusion has been drawn that milk is harmful in diabetes.
The deduction is the result of a too superficial process of reasoning. It would be
as logical to conclude that rest and warmth were harmful in the treatment of rheu-
matic conditions, from the fact that they lead to an increased discharge of urates.
In the case we are considering, the milk merely hastens the expulsion of sugar,
which is injuring and impeding the tissues, relieves the hematopoietic fimction,
and contributes to a cure, if the mistake is not made of overwhelming the blood-
forming organs by administering a quantity of milk beyond the metabolic powers
of the liver to deal with."

Afterward, potatoes, bread, and other elements of a mixed ration
are gradually added, with general admonitions against overeating.
Acidosis is not mentioned in the records of Guelpa's early "cures."
About 1911, something seems to have called his attention to acidosis,
for he suddenly (7) added a new chapter to his theory of diabetes.

HISTORY 53

Here he announces that diabetes is the type disease of hyperacidity.
Glycosuria is merely one of the multiple forms of defense of the organ-
ism against acidosis caused by food pernicious in its quantity and es-
pecially in its quality. There are several stages of the process, first
increase of urea, later glycosuria, later acetonuria, etc., and the sixth
and final stage is coma. The body defends itself by breaking down its
less useful elements, notably fat; an indication is the acetonujria, which
like the glycosuria is helpful and not harmful in the process of acidosis.
He denounces the overfeeding in the usual treatment of diabetes, and
denies that his method is unsuited for diabite maigre. As evidence,
he cites the example of a patient aged sixty-five years. This man
underwent a "cure" of five days' fasting with 40 gm. sodium sulfate
daily. The subsequent diet of vegetables, fruits, and 60 gm. bread
daily caused return of glycosuria, whereupon the five-day "cure" was
repeated, followed by a similar diet. The duration of this "dis-
toxication cure" was a month, and the result was that the patient be-
came free from his former glycosuria, albuminuria, and joint infection.
For threatened coma, Guelpa (7 and 11) advises copious drinks and
enemas of sugar and weak alkaline solutions, oxygen inhalations,
bleeding, and intravenous injections of physiological saHne or weak
alkali.

The Guelpa treatment has gained followers chiefly in France
and England. Cammidge ( (1), p. 343) mentions authors reporting
favorable results, but states that he has never been able to persuade
any patient to undergo it. A recent favorable report is by Hume.

Clear recognition should be accorded to Guelpa for the following
points of merit. First: without being guided by knowledge of earlier
undernutrition cures, and entirely from his own original and independ-
ent thought, he devised the first plan of treating diabetes by a radical
initial fast, longer than any previously recommended for this purpose.
Second: these fasts were repeated a number of times, with intervening
periods of diet very low in calories and protein and relatively rich in
carbohydrate, and the increase toward a living ration was made
gradually. Third : he emphasized loss of weight as a potent factor in
the improvement, and carried the reduction of weight to a more ex-
treme point than ventured by anyone before him, and did this even
in patients complaining of weakness. Fourth : he was first to demon-
strate the beneficial effect of fasting upon certain compUcations,

54 CHAPTER I

notably diabetic gangrene. The dietotherapy of gangrene is familiar
in text-books, but the important observation of Guelpa was that fasting
benefited the gangrene, instead of making it worse by weakening the
patient. Fifth: fasting periods were employed not only whenever
glycosuria or other symptoms appeared but also as a prophylactic
against their return. Certain' contrary facts must also be given
proper weight. The Guelpa treatment, in spite of its ease and sim-
plicity, failed of acceptance at the hands of diabetic specialists and
the immense majority of medical practitioners in all countries. The
explanation of this fact necessarily casts discredit either upon the
medical profession or upon this mode of treatment, and the latter
alternative is the true one. It is frequently repeated that the cases
treated successfully by Guelpa's method were severe, and that "the
usual anti-diabetic regime had failed;" but the details of the unsuc-
cessful diets are not given and the assertion cannot be accepted as cor-
rect in a single instance. In age, the patients were almost without ex-
ception above forty and frequently above sixty; many were obese;
their complaints were largely the natural consequence of their mode of
life at their time of life; on cessation of overeating and a lively purge
they were astonished how much better they felt, and their diabetes
was so slight that it was controlled by these simple measures with
little or no subsequent restriction of carbohydrate. The two most
severe cases of the series, namely that of the man described by Arnold*'
and that of the woman described by Bardet,^ cannot be considered

*^ Introduction to translation of Guelpa's book.

*^ Bardet narrates that in the therapeutic clinic of Beaujon was a woman with
diabetes of several years' duration, excreting 800 gm. sugar daily. Emaciation
was not extreme and acutely threatening symptoms were absent. Nothing re-
sembling the Naunyn treatment was undertaken. "She was placed for several
weeks under the ordmary treatment of M. Albert Robin, namely alternate medi-
cation with antipyrine and arsenic, without its being possible to reduce the
quantity of sugar below 160 gm. After a series of this medication, the patient was
left free from all treatment, and followed the routine diet of the diabetics of the
service : meat 500 gm., potatoes 500 gm., green vegetables 500 gm. At the time of
beginnmg the experiment (i.e. absolute fasting), she was passing 12 liters of urine in
24 hours, and on the final day showed an eh'mination of 760 gm. sugar." Here is
seen a combmation still too frequent in all countries; absence of rational treat-
ment, dependence on drugs, the use of routine instead of individualized diets, and
the physician's ignorance that the alleged sugar excretion on the diet stated is
impossible.

HISTORY 55

examples of severe diabetes; at the utmost, they would fall in the class
of "medium severity" according to von Noorden or Naunyn; they are
of the type easily cleared up under the Naunyn plan of regulated diet,
restricted protein, and intercalated fast-days, and neither of them
remained clear Tender the Guelpa method. So far from this method
being an improvement over the known treatment, a physician con-
fronted with the choice of referring a patient to Guelpa or to Naunyn
could have no possible ground for hesitation in choosing the latter.
The Guelpa plan is applicable only to mild diabetes, and here (not-
withstanding the quick temporary clearing of glycosuria) a permanent
success is attained only in a longer, harder, and less certain manner
than under the usual treatment. For diabetes of even moderate
severity, the attempt to fast, purge, and undernourish a patient until
he is able to tolerate carbohydrate-rich diet is inevitably disastrous.
In undertaking to apply the mode of treatment described in the pres-
ent monograph, the most common difl&culty and mistake of inexperi-
enced physicians has been to fast the patient till free from glycosuria,
then to give a diet permitting its return, then to fast, then to proceed
with improper diet, so that weight and strength are lost while tolerance
is injured instead of improved, and the end in any severe case will be
fatal. In the one young patient of his series, a youth of sixteen years,
with actually severe diabetes, Guelpa ( (5), p. 112) achieved sugar-
freedom after fifteen days, but relapse followed because the patient
finally found the program unendurable. There may be justifiable
surprise that Guelpa describes only successes; in his half dozen or less
of partially successful cases the blame for mishaps is placed entirely
upon the patients. Inasmuch as common knowledge and Guelpa's own
experience ( (1), p. 506) make it clear that purgation does not prevent
acidosis during fasting, it would be remarkable if so many diabetics
should be treated without encountering some of those severe cases of
long standing who go into fatal acidosis on fasting. There is still more
noteworthy absence of a record of any young patient with impending
coma who was cleared up and kept clear of both glycosuria and aci-
dosis. It is improbable that Guelpa avoided such cases altogether;
it is certain that his treatment must fail in the vast majority of them;
and his record of success limited to mild cases constitutes sufficient
evidence of his failure in more severe cases, even of the grade that can

56 CHAPTER I

be managed successfully under the Naunyn plan. On the one hand,
Guelpa should receive due credit for boldness, enthusia,sm, originality,
and some new observations growing out of a new clinical procedure.
On the other hand, it cannot be maintained that Guelpa devised a
good treatment for diabetes. The lesson of his work cannot be over-
looked; but the information and encouragement derivable from his

'long fasts in mild cases are less than from the shorter fasts of Naunyn
and von Noorden in severe cases, so that the proposed treatment of
severe cases by fasting is a development of the Naunyn method rather
than of the Guelpa method.

America has not been prolific of diabetic text-books. A notable
early example is that of Tyson, the frontispiece of which shows the
intraocular picture by which diabetic lipemia can be diagnosed.
■ The &st great contribution of this country to this subject was
Opie's hypothesis that diabetes is due to alterations in the islands of
Langerhans, on the basis of findings of hyaline, fibrous, and other
destructive changes in the islands in a series of cases where the acinar

■ tissue was relatively little affected.

Mandel and Lusk demonstrated the dextrose-nitrogen ratio of the
phloridzinized dog in a human diabetic, and drew attention to the
prognostic value of this ratio. Lusk's "Science of Nutrition" treats
a subject of such dominant importance for intelligent dietotherapy
that it may be placed in the highest rank among text-books of diabetes.
The most extensive investigation of the respiratory metabolism in
diabetes is that of Benedict and Joslin.

Hodgson treated over 1100 patients in the twenty years preceding
1911. He worked out a plan of treatment without drugs, using a
mildly alkaline mineral water freely. He held that patients "should be

kept mentally indolent and physically active One other

essential must be made' plain to the diabetic, and that is the quantity of

food eaten is just as important as the kind of food It is a

fact that many mild cases of diabetes will show a diminution of sugar
almost to the vanishing point when the patient is merely compelled
to eat a very moderate ordinary diet. That is to say an antidiabetic
diet is not always necessary to reduce the glycosuria; a reduction in the
amount of ordinary food will sometimes accomplish the same end.

' . . . . Again it should be stated that the quantity of all food, even

HISTORY 57

if it is carbohydrate-free, must be greatly restricted. The number of
calories that the body ordinarily requires is no safe criterion for the
amount of food that should be given a diabetic. It is not the quantity
of food that should be metabolized, but the quantity that can be me-
taboUzed that should determine the amount given to the patient. All
in excess of the quantity that the patient can actually use burdens the
already overtaxed excretory organs and retards improvement." In cases
severe enough that sugar did not disappear after two weeks of strict
diet, the patient was put to bed and allowed one raw egg and two
ounces of olive oil three or four times a day. If diacetic acid appeared,
the oil was diminished and some carbohydrate added. Hodgson's
statistics show a high percentage of favorable results in cases not too
severe in t}T)e.

Foster's manual (1915) is not only an excellent brief presentation of
the Naunyn system, but distinctly goes beyond this in the more radical
employment of undernutrition, with correspondingly better results.
He lays down the wise rule (p. 165) in contradiction to some European
authorities, that it is not safe to disregard diabetes even in advanced
life. By the use of repeated fast-days, vegetable days, and restricted
diet he achieves freedom from glycosuria in cases of the type given up
as hopeless by many writers. The procedure in such cases is slow,
and the control transitory (p. 216). "By the enforcement of rest in
bed and a stringent diet the urine can be freed of sugar in the vast
majority of cases. With early cases the result is often effected within
a few days; when the disease is advanced and there is a complicating

severe acidosis, months may be necessary These are the

most discouraging cases, as they never approach a semblance of health.
. . . . At once on beiiig released from incessant control, there is
an inevitable transgression beyond the path of safety in diet and exer-
cise. . . . . With severe cases of diabetes coma develops finally
in spite of the best endeavors."

Mosenthal applied the hospital class system to the care of diabetics.**
The method is particularly adapted to a disease in which instruction
of patients is so essential as in diabetes, and it is the most effective
practical measure in the organization of a clinic, both for the care of

^' Cf . Joslin ( (4), pp. 327 and 409) .

58 CHAPTER I

ambulant cases and for guarding against relapse in patients after dis-
charge from hospital. More widespread and effective social service
along these lines offers one of the most important means of diminishing
the death rate from diabetes.

Woodyatt (1) was one of the very few who in 1909 held clearly to
the conception of diabetes as a deficiency of the internal function of the
pancreas.'** Woodyatt (3) has recently suggested that the weakness
of the pancreatic function here concerned may not always be an in-
herited or constitutional defect in the Naunyn sense, but may some-
times be acquired, especially through infections which selectively
injure either the pancreas or the nervous mechanism cohtroUing it.

^ "Diabetes mellitus is a disease in which the body has in part lost its ability
to utilize sugars. Sugar arrives at the point where it should burn, but fails to do
so, and accumulating in the blood creates an hyperglycemia. Disregarding acces-
sory factors, which may play a part, we can say that ultimately the failure of sugar
combustion in diabetes mellitus depends upon lack of 'a something derived from
the pancreas.' The pancreas, like other glands, is capable of being stimulated intO'
a state of fatigue. It may be conceived that excess of sugar in the blood of healthy
individuals acts directly or indirectly (e.g. through nerves) as a stimulus to the
pancreas, as a result of which more internal secretion is set free and the excess of
sugar thereby automatically taken care of. This removed, the stimulating in-
fluence ceases and the pancreas rests. In diabetes it may be assumed that the
pancreas is functionally weak. A small excess of sugar in the blood, let us say,.
calls for a response from the pancreas, and as in health the excess may be removed.
Sooner or later, perhaps as a result of some dietary excess, or of some shock to the
nervous system which results in an outgush of sugar from the glycogen depots of
the liver, an unusual hyperglycemia occurs. This calls for a strong pancreatic
response, more than the functionally weak gland can give, and some excess of
sugar remains unutihzed in the blood. If hyperglycemia persists for any appreci-
able time the continuous pancreatic stimulation thereby engendered results in
glandular fatigue. Less and less secretion is elaborated, less and less sugar utilized,
the hyperglycemia grows progressively worse and a vicious circle becomes es-
tablished. The condition of the pancreas then corresponds to that of a heart with
broken compensation, and as the treatment for such a cardiac condition is rest, so
in diabetes rest is needed for the pancreas. To secure this we must control the
stimulating hyperglycemia, which means primarily the withdrawal of carbohy-
drates from the diet, secondarily reduction in the amount of protein, until absence
of glycosuria tells us that the blood sugar percentage is approximately normal.
After prolonged rest of this sort a return of the pancreatic function to its previous-
state is frequently spoken of as an increased body 'tolerance for sugar.'

Such restoration of sugar-burning capacity, such increase in 'tolerance' is the-

HISTORY 59

Raulston and Woodyatt in 1914 described a case of diabetes, for which
fasting had been used.^* Woodyatt (2) said at a symposium on dia-
betes before the Association of American Physicians in 1915: "For
eight years at the Presbyterian Hospital we have regularly used starva-
tion in the treatment of diabetes, following principles with which I
became acquainted in the clinic of Muller in Munich. We have fasted
patients for the purpose of desugarization for periods of one, two,
three, and in one case five days, and have kept patients for prolonged
' periods in semistarvation. There can be no doubt of its value in cer-
tain phases of treatment. As to its safety, I have seen two deaths
apparently from spread of infection immediately following a period
of fasting."

first aim of diabetic therapy. There are cases in which the ability of the
body to utilize carbohydrate has sunk so low that as a result certain secondary
changes in the fat metabolism have supervened. These changes are mainly re-
sponsible for the condition spoken of as acidosis. In health and in diabetes with-
drawal of carbohydrate from the diet frequently causes the appearance of a pre-
viously absent acidosis or an increase in the severity of an already existing one.
These aggravations are temporary. Still in such cases as already have a danger-
ously large amount of the acetone bodies in the blood no increase at all is per-
missible. In these cases, and only in these cases, should one refrain from an at-
tempt to improve tolerance. Just where to draw the line is a matter for individ-
ual judgment. Where means are at hand for accurate quantitative measurements
of the daily excretion of acetone bodies one may be justified in closely approaching
the danger point. When these means are not available a more respectful margin
of safety must be maintained."

*^ "We made a transfusion of blood into the veins of a patient suflfering from
diabetes mellitus, one for whom all known expedients had been exhausted and who

was approaching the end The patient, a man, aged thirty-four, had

first shownsymptomsofdiabetessixyearspreviously For two years the

symptoms had been severe, and for eighteen months prior to the transfusion he
had been constantly under observation in the Presbyterian Hospital, Chicago,
where on numerous occasions his metabolism had been studied for prolonged
periods. Prior to entering he had twice become unconscious with what had been
diagnosed as diabetic coma, and on several occasions afterward coma was
averted only by the enforcement of complete bodily rest and the use of maximum
doses of alkali and wine. He became fully educated with regard to the require-
ments of a metabolism study and voluntarily cooperated in a highly intelligent
way. He knew that the expectancy of life was very limited and solicited the
trying of any new line that might even temporarily mitigate his condition or

60 CHAPTER I

In the same discussion, Billings (1) spoke to similar effect.*^ Re-
cently Billings (2) has written, "In the service of the Editor in the
Presbyterian Hospital, Chicago, in collaboration with Dr. R. T.
Woodyatt, the treatment of diabetes by a preliminary absolute fasting
period, until the urine is sugar-free, has been followed for nine years.
We have fasted patients for as long as eight days. The patient is
encouraged to drink water freely. Acidosis usually diminishes
rapidly. One may give whisky or sour wine during the fasting period.
Soda bicarbonate may also be used in persistent acidosis. All that is '
said by Allen and Joslin concerning the treatment we can afSrm."

I^o clear up possible misunderstandings, the following may be
remarked:

(1) Friedrich Miiller has published nothing in regard to the principles attributed
to him. On the contrary, Staubli published (1908) the records of one clinic patient
and two private patients of Friedrich Miiller, showing that they were treated by
the Naunyn method, and though the treatment continued for a number
of months and the cases were not extremely severe, they continually showed marked
glycosuria and ketonuria and were dismissed with these still present. Further-
delay the end. On several occasions his glucose to nitrogen ratio closely approx-
imated 3.65 : 1 on a diet aggregating 2,500 calories (due allowance having been
made for ingested carbohydrate). Nevertheless his urine coiild always be
rendered sugar-free by fasting, and on semistaryation (the Falta-Lusk quotient)
could be reduced from 100 or thereabouts to the neighborhood of 50, as it was on
the diet used at the time of transfusion. During the time of observation the
patient remaiaed quietly in bed. Diet. — For two weeks prior to the transfusion
and for five days afterward the diet consisted of 800 cc. of 16 per cent cream, three
eggs (150 gm.), and water, clear tea or coffee to make the total volume of fluid two
liters daily." The patient died shortly after this time.

** "I am surprised to hear it said that the method of starvation of diabeticpatients
is new. We have used that method in Chicago for a number of years and patients
have been fasted for as long as eight days. The adoption of the method there was
due to the work of Woodyatt. A point to be remembered is that the study of
patients at rest in a hospital is only part of the problem; it is necessary to study
them after exercise, after return to ordinary mode of life. For years, I have taught
patients how to examine their own urine. While it may be harmful to give fats in
general in diabetes, butter fat is not harmful. Diabetics may take butter fat or
bacon fat and may do so for years. Whatever may be said, it is impossible ever
really to control diabetic patients; they will do as they please as soon as they get
beyond the observation of the doctor."

HISTORY 61

more, personal letters recently received show that Friedrich Miiller has no knowl-
edge of the proposed treatment, and considers it theoretically inadvisable because
of the supposed danger of acidosis.*' Such an attitude on the part of one so
widely informed concerning diabetes and so familiar with the Naunyn method,
affords some evidence of the newness of the proposed treatment and the principles
underlying it.

(2) Though Woodyatt states (1915) that an initial fast has been used for eight
years, and Billings (1916) that it has been used for nine years, the above quoted
therapeutic program of Woodyatt (1) makes no mention of the use of such a
method in 1909; on the contrary, it is there advised, in harmony with Naunyn,
that in cases with very dangerous acidosis one should "refrain from an attempt to
improve tolerance." No description of the new method has since been pubHshed
by either of these authors.

(3) The paper of Raulston and Woodyatt makes incidental reference to fasting
and semistarvation. It seems evident that the plan of fasting used and referred to
by these authors resembled that of von Noorden, the only difference being that the
periods were sometimes longer; the effect is a temporary cessation of glycosuria

*' One letter was addressed to Professor Graham Lusk, and another to one of the
present authors. Liberty is taken to quote from the latter, under date of August
1,1915.

"Die Frage einer kalorisch armen Ernahrung bei Diabetes ist vor einigen Jahren
in der deutschen Literatur durch Schlesinger erortert worden, und er hat gezeigt,
dass Diabetiker haufig bei einer an kalorieri auffallend armen Nahrung sich erhal-
ten. Ein Nutzen fiir die Kranken wird aus dieser Arbeit nicht erkenntlich. Dann
hat Weintraud vor Jahren in seinen aus der Naunynschen Klinik kommenden in
der Bibliotheka medica erschienenen Arbeit auf die Bedeutung einer zeitweiligen
Unteremahrung hingewiesen, und Sie finden diese Gesichtspunkte in dem Buch von
Naunyn iiber Diabetes ausfiihrlich dargelegt. Wir verwenden in Deutschland
zeitweiUge Unteremahrung, sogenannte Hungertage, ganz gewohnHch zur Re-
duktion des Zuckers, und scheuen uns nicht das Korpergewicht dadiirch zu re-
duzieren. Freilich gelingt es nur selten durch solche Hungertage die Acidosis zu
vermindern, da ja der Hunger an sich auch bei gesunden Menschen ausgesprochene
Acidosis zu erzeugen pflegt. Jeder Hungerzustand fiihrt zu Verbrennung von
Korperfett imd erzeugt daher bei Mangel an Glykogen eine Acidosis. Bei Dia-
betes, wo der Glykogenvorrat ohnedies reduziert ist, und wo die Zuckerverbren-
nung haufig schwer geschadigt ist, tritt die Hungeracidosis gewohnlich noch
starker hervor, und erschwert die Behandlung durch Unteremahrung. Eine
generelle Verordnung der Unterernahrang bei Diabetes dtirfte schon aus dem
Grunde nicht ganz ohne Bedenken sein, well die Diabetiker unter einander so un-
geheuere Verschiedenheiten zeigen, dass man sich hiiten muss alle Falle nach der-
selben Regel zu behandeln. Das letzte Wort in dieser Frage hat jedenfalls nur die
Erfahrung, nicht aber die Theorie."

62 CHAPTER I

and diminution of ketonuria at the price of a certain amount of weiglit and nutri-
tion, but the diet after the fast permits a quick return of the symptoms. It is
expressly stated that in the semistarvation periods the Falta-Lusk quotient^* was
still about 50, which means serious glycosuria; and it is obvious that marked
ketonuria was constantly present. Billings' opinion concerning fat, and the high
fat diet used by Raulston and Woodyatt, suffice to explain such a result, for without
fat restriction these patients cannot be kept free from such symptoms.

Misunderstanding of the incomplete description of the method in the brief pre-
liminary communications was evidently responsible for the early criticisms of this
character. Aside from the fundamentally new principle of total caloric regulation,
it has been necessary to develop many practical details. The discussion of the
resulting system has in general remained free from questions of priority.

Joslin has had the largest experience in the treatment of severe dia-
betes in this country, and has published the latest as well as the most
advanced and authoritative text-book. No other American clinician
has followed the scientific study of diabetes so long and intensely.
His careful records cover approximately 1000 diabetic patients treated
during the past eighteen years, and are particularly valuable because
the great majority of the cases have been accurately followed up to
death or to the present time. His definition is one which when gener-
ally adopted will tend to lower the death rate from diabetes and its
complications. "My rule in the treatment of diabetes is to consider
any patient to have diabetes mellitus and treat him as such, until the
contrary is proven, who has sugar in the urine demonstrable by any of
the common tests. This method of procedure is safer for the patient
than to make use of the term glycosuria, which begets indifference."
He has laid emphasis upon the necessity of keeping patients supplied
with sufficient quantities of fluid and salts. He has been closely in
touch with the development of the fasting treatment from the outset.
He was informed in advance concerning the first clinical results, and
has treated a greater number of severe cases of diabetes by this method
than any other individual. The rapid general adoption of the method
has been largely due to his example and influence, and in his various
publications he has formulated a detailed program which many prac-
titioners have followed. The reversal of conditions is shown by the
fact that whereas fat was formerly the only food not restricted,

«Cf.Lusk(2).

HISTORY 63

Joslin now begins treatment by withdrawing only fat. His statistics
-support the belief that the life of diabetic patients is lengthened by the
new method, and in his judgment they enjoy also better strength and
'Comfort. References to and comparison with Joslin's results afford
valuable information on the questions discussed in the ensuing chap-
ters, and certain topics can be here omitted altogether because of the
manner in which he has handled them on the basis of a wider experience.

One of the present writers*' previously published work which seemed
to promise the possibility of investigating diabetic therapy by animal
experiments. The conception underlying the subsequent research at
this Institute had a threefold origin. One lay in considerations from
the literature as above mentioned, and also the reports of cessation of
'diabetes in various forms of cachexia {loc. cit., p. 800 ff.). The second
was found in certain of the preceding observations; viz., that in dogs
with severe diabetes not too far advanced, glycosuria ceased and tiie
diabetes seemed more or less improved on fasting alone {loc. cit., p. 480,
Dog 64), or together with ligation of the pancreatic duct (Chapter
XXII). The latter experiments were repeated and the role of im-
paired food absorption and undernutrition demonstrated by Homans.
The third suggestion was furnished by Joslin,^" who in a conversation
-called attention to his observations that though infections are gener-
;ally so serious in diabetes, tuberculosis with rapid emaciation had
•seemed sometimes, notably in one very carefully studied case, to be
.accompanied by diminution of both glycosuria and acidosis.

On these various grounds, animal experiments were begun with a
view to the possibility that diabetes is a disorder of the total metabo-
lism and not of carbohydrate utihzation alone, that the entire diet and
maintenance of the entire body mass constitute a load upon the inter-
nal function of the pancreas, and that accordingly in the treatment of
•diabetes increase of diet and of body weight increases the strain upon
this function, and reduction of the total diet and weight relieves this
;;strain more effectively and permanently than restriction of carbo-
hydrate alone. A series of animal experiments seemed to support this

« Allen (1).

^ Cf. Benedict and Joslin, p. 55, Case R; also Joslin, Treatment of Diabetes
:Mellitus, 2nd edition, 1917, p. 409.

64 CHAPTER I

conception, which was then applied to the treatment of diabetic
patients. Some of the results have been outlined in preliminary
communications, which, however, have not been sufficient to convey
an accurate knowledge of the details, and results have varied somewhat
with the different appHcations of the method in different hands.

Among authors who have reported favorable experiences are: in
America, Barker, Bookman, Christian, Friedenwald and Limbaugh,
Greeley, Halsey, Hamburger, Heffron, Heyn and Hawley, Hill and
Eckman, Hill and Sherrick, Jeans, Jones, Lemann, Levy, Lovewell,
Marshall, Martin and Mason, McNabb, Moses, Paley, Potter, Rob-
bins, Stengel and collaborators, Strouse, and Wilhams; in England,
Cammidge, Fenwick, Leyton, Spriggs, and speakers discussing their
papers; in Ireland, Nesbitt; in India, Waters. Its adoption by
speciahsts and institutions, and by a still greater number of general
practitioners, has furnished gratifying evidence not only of its theo-
retical soundness but also of its feasibihty for successful practical
application under the many varied conditions of medical work and
environment. Geyelin and DuBois, and Jonas and Pepper, have
demonstrated the possibility of beneficial results in the most intense
uncomplicated cases ever described in the literature of diabetes.

Aside from any benefits inherent in the treatment itself, it has
apparently served to stimulate interest in diabetes among members of
the medical profession, and to promote the understanding and employ-
ment of rational dietetic management of this disorder, than which
none has been more poorly understood or treated. Such knowledge
and confidence concerning the rational therapy will diminish the use
of the worthless or harmful remedies which appeal to ignorance or
despair. The history of the development of the scientific treatment,
and of some among the many contributors to it, may;fittingly be closed
with a quotation from Naunyn ( (5) , p. 452) . "The interest in novelty
may be granted also to physicians, and the lack of prejudice with
which we accept for trial all things, even the strangest and from the
worst source, may — so far as one may believe in it — ^be praised; but
every physician must beware of undertaking such special treatments
or of recommending them, without ascertaining their relation to what
science has estabHshed and teaches concerning the therapy of our
disease. If this is not possible for him, then the employment of them

HISTORY 65

is not permissible. The therapy of diabetes has been well founded by
painstaking labor highly fruitful in all directions; we may be proud of
that which has been achieved and attained here. The physician who
here frivolously abandons the scientific basis must, if he wishes to be
deemed honorable, submit to the accusation of ignorance."

BIBLIOGRAPHY.

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66 CHAPTER I

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(3) Les hydrates de carbone dans le traitement du diabete sucre, Semaine

mid., 1911, xxxi, 313-318.
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cii, 1240-1242.
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1054.
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Paris, 1851.
(2) De la glycosurie ou diabete sucre, Paris, 1875.
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(2) The Nitrogen Balance in Diabetes MeUitus and Its Importance in

Treatment, Lancet, 1915, ii, 1187-1189.

(3) The New Dietetic Treatment of Diabetes, Ibid., 1917, ii, 522-527.

(4) The New Dietetic Treatment of Diabetes, Brit. Med. J., 1917, i, 503-505.

(5) The Importance of Regulating the Fat-Intake in Diabetes Mellitus,

Ibid., 1918, i, 393-395.
Camplin, J. M., On Diabetes, and Its Successful Treatment, London, 1858.
Cantani, A., (1) Der Diabetes mellitus, translation by Siegfried Hahn, Berlin, 1877.
(2) Le diabete sucre et son traitement dietetique, translation by H. Charvet,
Paris, 1878.
Cawley, T., A singular Case of Diabetes, consisting entirely in the Quality of
the Urine: with an Inquiry into the different Theories of that Dis-
ease, London Med. J., 1788, ix, 286-308.
Chevallier, a., Sur I'urine des diab6tiques, J. chim. mSd., pharm., et toxical.,

1829, V, 7-12. Ref. by Griesinger.
Chevreul, (1) Note sur le sucre de diabetes. Bull. Soc. philomatique, 1815,
148-149.
(2) Note sur le sucre de diabetes, Ann. chim. et phys., 1815, xcix, 319-320
Ref. by Lepine.

HISTORY 67

Christian, H. A., The Starvation Method versus Gradual Carbohydrate Re-
duction as a Time Saver in the Treatment of Diabetes, Boston Med.

and Surg. J., 1915, ckxii, 929-933.
Christie, T., Notes on Diabetes Mellitus, as It Occurs in Ceylon, Edinburgh

Med. and Surg. J., 1811, vii, 285-299.
CsONKA, F. A., The Fate of Ingested Starch in Phlorhizin Diabetes, J. Biol.

Chew.., 1916, xxvi, 327-329.
CuLLEN, G. E., Studies of Acidosis. III. The Electrometric Titration of Plasma

as a Measure of Its Alkaline Reserve, J. Biol. Chem., 1917, xxx,

369-388.
CuLLEN, W., (1) First Lines on the Practice of Physic, Edinburgh, 1st edition,

1776-1784.
(2) Synopsis Nosologiae Methodicae, Edinburgh, 1769. Ref. in texts.
DiNGUizLi, Diabete sucre et son traitement sans regime, d'apres les auteurs

arabes anciens. Bull. Acad, mid., 1913, Ixx, 629-635. (Report by A.

Robin.)
DoBSON, M., Experiments and Observations on the Urine in Diabetes, Medical

Observations and Inquiries by a Society of Physicians in London,

1776, V, 298.
DoNKiN, A. S., (1) On the Relation between Diabetes and Food and Its Appli-
cation to the Treatment of the Disease, London, 1875.
(2) The Skim-Milk Treatment of Diabetes and Bright's Disease, London,

1871.
VON During, A., Ursache und Heilung des Diabetes mellitus, Hanover, 2nd

edition, 1875. Ursache und Heilung der Zuckerkrankheit, Hanover,

5th edition, 1905.
DuPTJYTREN and Thenard, Memoire sur le diabetes sucre, /. med., chir.,

pharm., etc., 1806, xii, 77-111; Bull. Faculte Med. Paris, 1812,

i (1806), 37-42.
Ebstein, W., (1) Uber Driisenepithelnekrosen beim Diabetes mellitus mit be-

sonderer Beriicksichtigung des diabetischen Coma, Deutsch. Arch.

klin. Med., 1881, xxviii, 143-242.

(2) Die Zuckerharnruhr, ihre Theorie and Praxis, Wiesbaden, 1887.

(3) Ueber die Lebensweise der Zuckerkranken, Wiesbaden, 2nd edition,

1898.

(4) Beitrag zum respiratorischen Gaswechsel bei der Zuckerkrankheit,

Deutsch. med. Woch., 1898, xxiv, 101-102.
Falta, W., (1) Die Therapie des Diabetes mellitus, Ergebn. inn. Med. u. Kinderh.,

1908, ii, 74-141.
(2) Ueber die gemischte Amylazeenkur bei Diabetes mellitus, Milnch.

med. Woch., 1914, Ixi, 1218-1220.
Faroes, F., L'assimilation du sucre de lait chez le diabetique; une therapeutique

rationelle du diabete, Gaz. hebd. sc. mid. Bo^(ieoMx, 1915, xxxvi, 33-37.

68 CHAPTER I

Feeling, H., Ueber die quantitative Bestimmung von Zucker und Starkemehl
mittelst Kupfervitriol, Ann. Chem. et Pharm., 1849, Ixxii, 106-113;
Chem. Pharm. Centr., 1850, xxi, 244-246.

Fenwick, p. C. C, Notes on the Starvation Treatment of a Young Diabetic,
Lancet, 1917, i, 299.

FiTZ, R., (1) Acetone Bodies in the Blood in Diabetes, Tr. Assn. Am. Phys.,
1917, xxxix, 155-158.
(2) Observations on Kidney Function in Diabetes Mellitus, Arch. Int.
Med., 1917, xx; 809-827.

FiTZ, R., and Van Slyke, D. D., Studies of Acidosis. IV, The Relationship be-
tween Alkaline Reserve and Acid Excretion, /. Biol. Chem., 1917,
XXX, 389-400. , ■

Foster, N. B., Diabetes Mellitus, Philadelphia and London, 1915.

VON Freeichs, F. T., (1) R. Wagner's Handworterbuch der Physiol., 1846, iii,
'part 1), 803.

(2) Ueber den plotzlichen Tod und fiber das Coma bei Diabetes (dia-

betische Intoxication), Z. klin. Med., 1883, vi, 1-53.

(3) Ueber den Diabetes, Berlin, 1884.

Friedenwald, J., and Limbaugh, L., The Allen Treatment of Diabetes, Inter-
state Med. J., 1916, xxiii, 73-79.

Gerhaedt, C, Zur Aetiologie und Therapie des ninden Magetageschwlirs, Wien.
med. Presse, 1868, vi, 1.

Geyelin, H. R., and Du Bois, E. F., A Case of Diabetes of Maximum Severity
with Marked Improvement. A Study of Blood, Urine and Respira-
tory Metabolism, J. Am. Med. Assn., 1916, Ixvi, 1532.

Greeley, H. P., Diabetes Mellitus. Broader Aspects of Treatment and Re-
sults, J. Am. Med. Assn., 1917, Ixviii, 1685-1689.

Gregory, G., Elements of the Theory and Practice of Physic, London^ 2nd
edition, 1825.

Griesinger, W., Studien iiber Diabetes, Arch, physiol. Heilk., 1859, iii, 1-75.

Guelpa, G., (1) Cure du diabete (and Discussion), Bull. gin. thSrap., 1909,
clvii, 91-105, 494-508; Nouvelle contribution a I'dtude da la purga-
tion. Ibid., 770-789.

(2) Sur la purgation. Ibid., 1909, clviii, 182-189, 213-221.

(3) R6sultats eloignes de 19 cas de diabete trait^s par la m6thode de desin-

toxication, Ibid., 1910, clix, 213-221.

(4) Autointoxication et disintoxication, Paris, 1910.

(5) Autointoxication and Disintoxication, translation by F. S. Arnold, New

York, 1912.

(6) Starvation and Purgation in the Relief of Disease, Brit. Med. J., 1910,

ii, 1050-1051.

(7) Interpr6tation des manifestations diab6tiques, traitement du diabete,

Bull. gSn. thirap., 1911, clxii, 925-931.

(8) La goutte, son traitement, Ibid., 1912, clxiv, 709-716.

HISTORY 69

GuELPA, G., (9) Hygiene des chevaux et regime vegetarian. La goutte, (review
in Lyon Mid., 1913, cxxi, 1082-1084).

(10) Proc. Internal. Cong. Med., 1913, vi, 392, (brief remark).

(11) Desintoxication de I'organisme, Paris, 1913, (review in Lyon MSd.,

1913, cxx, 1204-1206).
GuELPA, G., and Makie, A., La lutte contre I'epilepsie par la disintoxication et

par la reeducation alimentaire. Bull. gin. ihhrap., 1910, clx, 616-624.
Hallervorden, E., Ueber Ausscheidung von Ammoniak im Urin bei patholo-

gischen Zustanden, Arch. exp. Path. u. Pharm., 1880, xii, 237-275.
Halsey, J. T., (1) The Allen Treatment of Diabetes, New Orleans Med. and

Surg. J., 1915-16, Ixviii, 501-509.
(2) The Dietetic Treatment of Surgical Diabetes, South Texas Med. Rec,

1916, X, 10-13.
Hambitrger, W. W., The Allen Treatment of Diabetes, Med. Clinics Chicago,

1916, i, 1051-1075.
Harley, G., Diabetes, Its Various Forms and Different Treatments, London,

1866.
Heffron, J. L., The New Conception of Diabetes and Its Treatment, iV. Y. State

J. Med., 1916, xvi, 69-71.
Heyn, L. G., and Hawley, P. R., The Allen Treatment of Diabetes Mellitus,

Lancet-Clinic, 1915, cxiv, 42-45.
Hill, L. W., and Eckman, R. S., The Starvation Treatment of Diabetes. With

a Series of Graduated Diets, Boston, 1915, 1916, 1917.
Hill, L. W., and Sherrick, J. L., Report on the Allen Treatment of Diabetes,

Boston Med. and Surg. J., 1915, clxxii, 696-700.
HiRSCH, A., Handbook of Geographical and Historical Pathology, translation

by Charles Creighton, New Sydenham Society, London, 1885, ii.
Hirschfeld, F., Ueber eine neue klinische Form des Diabetes, Z. kUn. Med.,

1891, xix, 294-304, 325-359.
Hodgson, A. J., Treatment of Diabetes Mellitus, /. Am. Med. Assn., 1911, Ixvii,

1187-1191. Diabetes Mellitus, Canad. Med. Assn. J., 1912, xli, 874-

891.
Homans, J., A Study of Experimental Diabetes in the Canine and Its Relation

to Human Diabetes, /. Med. Research, 1915-16, xxxiii, 1-51.
Home, F., Clinical Experiments, Histories, and Dissections, Edinburgh, 1780.

Ref. in texts.
Hopkins, F. G., Dr. Pavy and Diabetes, Science Prog., 1912, vii, 13-47.
IwAi, T., Le diabete sucr6 chez les Japonais, et son 6tude comparative avec le

diabete observg en Europe et en Am6rique, Arch. mid. exp. et anat.

path., 1916, xxvii, 1-54, translation by J. LeGoS.
Jastrowitz, H., Experimentelle Untersuchungen iiber die therapeutische Wir-

kungsweise des Hafermehles, Z. exp. Path. u. Therap., 1912-13, xii,

207-220.

70 CHAPTER I

Jonas, L., and Pepper, 0. H. P., Acute Diabetes with Enormous Elimination of

Nitrogen: Report of Case with at Least Temporary Recovery, /. Ant.

Med. Assn., 1917, kviii, 1896-1897.
Jones, N. W., On the Clinical Application of the Newer Methods of Treatment

of Diabetes Mellitus, Northwest Med., 1917, xvi, 38-41.
JosLiN, E. P., (1) Present-Day Treatment and Prognosis in Diabetes, Am. J.

Med. Sc, 1915, cl, 485-496.

(2) Carbohydrate Utilization in Diabetes, Arch. Int. Med., 1915, xvi, 693-

732.

(3) Pregnancy and Diabetes Mellitus, Boston Med. and Surg. J., 1915,

clxxiii, 841-849.

(4) The Treatment of Diabetes Mellitus, Philadelphia and New York, 1916,

2nd edition, 1917.
JosLiN, E. P., Brigham, F. G., and Hoenor, A. A., An Analysis of Fourteen

Cases of Diabetes Mellitus Unsuccessfully Treated by Fasting,

Boston Med. and Surg. J., 1916, clxxiv, 371-378, 425-429.
Kahn, M., and Kahn, M. H., Lime Therapy of Diabetes, Med. Rec, 1915,

Ixxxviii, 744-746.
The Lime Deficiency of Diabetes, Arch. Int. Med., 1916, xviii, 212-227.
Kaeell, P., De la cure de lait, Arch. gin. med., 1866, (2), 513-533, 694-704.
Kaulich, J., Ueber Acetonbildung im thierischen Organismus, Vrtljschr. prakt.

Heilk., 1860, Ixvii, 58-72.
Klemperer, G., (1) Ueber regulatorische Glykosurie und renalen Diabetes (Dis-
cussion), Berl. klin. Woch., 1896, xxxiii, 571.
(2) Die Verwertung reinen Traubenzuckers bei schweren Diabetikern,

Therap. Gegenw., 1911, lii, 447-452.
KoLiscH, R., (1) Lehrbuch der diatetischen Therapie, Leipsic and Vienna,

1899.
(2) Zur d'atetischen Behandlung des Diabetes mellitus, Wien. klin. Woch.,

1899, xii, 1305-1308.
KOLISCH, R., and Schuman-Leclerq, F., Zur Frage der Kohlehydrattoleranz

der Diabetiker, Wien. klin. Woch., 1903, xvi, 1321-1323.
KtJLZ, R. E., (1) Beitrage zur Pathologie und Therapie des Diabetes mellitus,

Marburg, 1874.

(2) Klinische Erfahrungen tiber Diabetes mellitus, (Rumpf, AldehoflF,

Sandmeyer), Jena, 1899.

(3) Zur Prioritatsfrage bezuglich der Oxybuttersaure im diabetischen Harn,

Arch. exp. Path. u. Pharm., 1884, xviii, 290.
KussMAUL, Zur Lehre vom Diabetes mellitus, Deutsch. Arch. klin. Med., 1874,

xiv, 1-46.
Labbe, M., (1) Tol6rance comparee des divers hydrates de carbone par I'organ-

isnie des diabetiques, Bull, et mim. Soc. mid. Mp. Paris, 1907, xxiv,

221-234.

Ref. by L6pine
and Sauerbeck.

HISTORY 71

Labbe, M., (2) La cure de Mgumes sees chez les diabetiques, Bull, Acad, med.,
1914, Ixxi, 52-54.

(3) Die Diat beim Diabetes gravis, Med. Klin., 1913, ix, 1973-1978.

(4) Les cures de 16gumes sees dans le diabete, Rev. med., 1914, xxxiv,

473-503.
Lampe, E., Haferkuren bei Diabetes mellitus, Z. physik. u. diiUet. Therap., 1909-10,

xiii, 213-231.
Lampe, E., and Strassner, H., Blutzuckerwerte der verschiedenen Diatformen

bei Diabetes, Med. Klin., 1913, ix, 1462-1465.
Lancereaux, E., (1) Note sur un cas de syphilis pulmonaire,

suivie de reflexions sur la syphilis des visceres

et les erreurs dont elle est I'objet, Bull. Acad.

mid., 1877, vi, 1108-1120.

(2) Nouveaux faits de diabete sucre avec alteration du

pancreas, Ihid., 1888, xix, 588-609.

(3) Le diabete maigre: ses sympt6mes, son evolution,

son prognostic et son traitement; ses rapports
avec les alt6rations du pancreas. — fitude com-
parative du diabete maigre et du diabete gras,
Union Med., 1880, xxix, 161-167; 205-211. Lcfons
de clinique medicale (Review), /6«i.,1890, xiv,
439-441.

Lapierre, a., Sur le diabete maigre dans ses rapports avec les alterations du
pancreas, These de Paris, 1879. Ref. by Lepine and Sauerbeck.

Latham, J., Facts and Opinions concerning Diabetes, London, 1811.

Lemann, 1. 1., The Allen Treatment in Diabetes by Fasting, /. Am. Med. Assn.,
1915, Ixv, 2118.

Lenn£, a., (1) Wesen, Ursache, und Behandlung der Zuclierkrankheit, Berlin,
1898.

(2) Die Eiweisszufuhr in der Diabetesdiat, Verhandl. Cong. inn. Med.,

1900, xviii, 587-600.

(3) Ein weiterer Beitrag zur Diatregelung und medikamentosen Behand-

lung des Diabetes mellitus, Therap. Gegenw., 1907, ix, 251-255.
Leo, H., Ueber die Stickstoffausscheidung der Diabetiker bei Kohlehydratzu-

fuhr, Z. klin. Med., 1893, xxii, 225-244.
Lepine, R., (1) Le diabete sucre, Paris, 1909.

(2) Fortschritte in der Behandlung des Diabetes mellitus seit 50 Jahren,

Berl. klin. Woch., 1913, 1, 477-481.

(3) Progres de nos connaissances sur la pathogenic et le traitement du

diabete sucre et de I'acetonSmie, Rev. med., 1913, xxxiii, 449-473,
601-624, 769-783.
Levy, L. H., Diabetes. The Complications and Treatment; the Allen Plan,
N. Y. Med. J., 1915, cii, 1192-1195.

72 CHAPTER I

Leyton, O., (1) Discussion on the Treatment of Diabetes Mellitus by Alimentary
Rest, Proc. Roy. Soc. London, 1915-16, ix, Therap. and Pharm.
Sect., 63-76. Also 76-90, (Spriggs).

(2) The Treatment of Diabetes Mellitus by Alimentary Rest, Practitimer,

1916, xcvii, 24-43, 401-429.

(3) The Modem Treatment of Diabetes Mellitus, Brit. Med. J., 1917,

i, 252-^254.
LiPETZ, S., Ueber die Wirkung der v. Noorden'schen Hafercur beim Diabetes

melitus, Z. klin. Med., 1905, Ivi, 188-197.
LovEWELL, C. H., Modern Treament of Diabetes, Illinois Med. J., 1917, xxxi,

240-245.
Lrsz, G., (1) The Elements of the Science of Nutrition, Philadelphia, 2nd
edition, 1909; 3rd edition, 1917.
(2) Metabolism in Diabetes, /. Am. Med. Assn., 1910, Iv, 2105-2107.
Magendie, (1) Note sur la prfisence normale du sucre dans le sang, Compt.
rend. Acad., 1846, xxiii, 189-193; Gaz. mSd., 1846, 734-736, ref. Vogel,
J., Pathologic des Bluts, Canstatt's Jahresh., 1846, iii, 27.
Magnus-Levy, A., (1) Die Oxybuttersaure und ihre Beziehungen zum Coma
diabeticum. Arch. exp. Path. u. Pharm., 1899, xlii, 149-237.
(2) Diabetes mellitus, SpezieUe Pathologic und Therapie innerer Krank-
heiten (Kraus and Brugsch), 1913, i, Tl. 1, 1-85.
Mandel, a. R., and Lusk, G., (1) Diabetes Mellitus. — Report on a Case, Includ-
ing a New Method of Prognosis, /. Am. Med. Assn., 1904, xUii, 241.
(2) StofiEwechselbeobachtungen an einem FaUe von Diabetes mellitus, mit
besonderer Beriicksichtigung der Prognose, Deutsch. Arch. klin.
Med., 1904, Ixxxi, 472-492.
Marsh, H., Observations on the Treatment of Diabetes Mellitus, Dublin Quart.

J. Med. Sc, 1854, xvii, 1-19.
Marshall, M., The Starvation Treatment of Diabetes, /. Michigan Med. Soc,

1916, XV, 150-151.
Martin, C. F., and Mason, E. H., Observations on the Starvation Treatment of

Diabetes, Am. J. Med. Sc, 1917, cliii, 50-58.
McNabb, E., The Treatment of Diabetes after the Method of Allen, /. Ten-
nessee State Med. Assn., 1915-16, viii, 477-481.
Menke, J., Ueber das Verhalten des Blutzuckers bei Kohlehydratkuren und tiber
den Wert der Blutzuckerbestimmungen fur die Therapie des Dia-
betes, Deutsch. Arch. klin. Med., 1914, cxiv, 209-248.
VON Mering, J., (1) Ueber die Abzugswege des Zuckers aus der Darmhohle,
Arch. Physiol., 1877, 379-415.

(2) Ueber experimentellen Diabetes, Kong. inn. Med., 1886, v, 185-189.

(3) Behandlung des Diabetes mellitus und insipidus, Handbuch spez.

Therapie, Renzoldt and Stintzing, 1895, ii, 3te. Abt., 59-104.
VON Mering, J., and Minkowski, 0., Diabetes mellitus nach Pancreasexstirpa-
tion. Arch. exp. Path., u. Pharm., 1889-90, xxvi, 371-387.

HISTORY 73

M'Gregoe, R., Comparative State of Urea in Healthy and Diseased Urine, and
the Seat of the Formation of Sugar in Diabetes Mellitus, London
Med. Gaz., 1837, xx, 268-272.

MiALHE, L., (1) Apercu theorique sur la cause de la maladie d6signee sous le
nom de diab&te ou de glycosurie, Compt. rend. Acad., 1844, xviii, 707.

(2) De la digestion et de I'assimilation des matieres sucrees et amiloides,

Ibid., 1845, XX, 954-959.

(3) Traitement raisonne du diabete par les substances alcalines, /. mSd. et

ckir. prat., 1846, xvii, 23-24; Formule du traitement du diabete sucr6
par les substances alcalines, Ibid., 77-78; ref. Vogel, J., Pathologie
des Bluts, Canstatt's Jahresb., 1846, iii, 29.

(4) NouveUes recherches sur la cause et le traitement du diabete sucre ou

glucosurie. Bull. Acad, mid., 1847, xiii, 1224; Bull, therap., 1849,
xxxvi, 198-208. Ref. by Lepine.

(5) Nouvelle th6orie du diabete sucr6 ou glycosurie. Union Mid., 1866,

XXX, 218-221, ref. by Lepine; also Arch. gin. mid., 1866, i, 746.
MiALHE, L., and Contour, Observation d'un cas de diabete sucr6 traits et gueri

par I'emploi des alcalis et des sudorifiques, Compt. rend. Acad., 1844,

xix, 111-112.
Minkowski, O., (1) Ueber das Vorkommen von Oxybuttersaure im Ham bei

Diabetes mellitus. Arch. exp. Path. u. Pharm., 1884, xviii, 35-48.

(2) Nachtrag iiber Oxybuttersaure im diabetischen Harne, Ibid., 147-150.

(3) Untersuchungen iiber den Diabetes mellitus nach Exstirpation des

Pankreas, Ibid., 1892-3, xxxi, 85-189.

(4) Die neueren Anschauungen iiber den Diabetes mellitus, Med. Klin.,

1911, vii, 1031-1036. The Newer Opinions concerning Diabetes
Mellitus, translation by G. Lusk, Med. Rec, 1913, Ixxxiii, 220-225.

MosENTHAL, H. 0., The Treatment of Diabetes Mellitus in Dispensaries, Med.
Rec, 1915, Ixxxvii, 589-592.

Moses, H. M., The Present Treatment of Diabetes Mellitus, Med. Rec, 1916,
xc, 1069-1072.

MossE, A., La cure de pommes de terje dans les diabetes sucr6s et les compli-
cations diabetiques. Rev. mid., 1902, xxii, 107-121, 279-308, 371-
411, 620-658, 1098.

Naunyn, B., (1) Zur Pathologie und Therapie des Diabetes mellitus, Verhandl.
Cong. inn. Med., 1886, v, 183-184.

(2) Die diatetische Behandlung des Diabetes mellitus, Samml. klin. Vortr.,

1889, (Innere Medicin, No. 116), 3129-3168.

(3) Nephritis und Diabetes und Nierendiabetes, Z. prakt. Aerzie., 1898, vii,

525-530.

(4) Der Diabetes melitus, Deutsch. Klin., 1902, iii, 1-34.

(4A) Die Behandlung des Diabetes melitus, Deutsch. med. Woch., 1905,
xxxi, 977-982.

74 CHAPTER I

Naunyn, B., (S) Der Diabetes melitus, Vienna, 1906.

(6) Diatetische Behandlung der Glykosurie und des Diabetes, Z. artzl.

FortUld., 1908, v, 737-746.
Nesbitt, G. E., Remarks on the Alien Treatment of Diabetes, Dublin J. Med.

Sc, 1916, cxlii, 379-385.
Nicolas, and Gueudeville, V., Recherches et experiences medicales et chimi-

ques sur le diabete sucre ou la phthisurie sucree, Paris, 1803. Ref.

by Sauerbeck and others.
VON NoOEDEN, C., (1) Die Zuckerkrankheit und ihre Behandlung, Berlin, 6th
• edition, 1912.

(2) New Aspects of Diabetes, New York, 1912.

(3) Die Diat bei Diabetes gravis, Med. Klin., 1913, ix, 611-616.

Opie, E. L., (1) On the Relation of Chronic Interstitial Pancreatitis to the Islands

of Langerhans and to Diabetes Mellitus, /. Exp. Med., 1900-1901, v,

397-428.
(2) Diabetes MeUitus Associated with Hyalin Degeneration of the Islands

of Langerhans of the Pancreas, Bull. Johns Hopkins Hosp., 1901,

xii, 263-264.
Opplee, B., and KiJLZ, C., Ueber das Vorkommen von Diabetes mellitus bei

Ehegatten (Uebe'rtragbarkeit des Diabetes mellitus), Berl. klin.

Woch., 1896, xxxiii, 583-586, 612-615.
Paley, S. H., The Allen Treatment in Diabetes MeUitus, N. Y. Med. J., 1916,

ciii, 159-161.
Palmer, W. W., The Concentration of Dextrose in the Tissues of Normal and

Diabetic Animals, /. Biol. Chem., 1917, xxx, 79-114.
Palmer, W. W., and Van Slyke, D. D., Studies of Acidosis. IX. Relationship

between Alkali Retention and Alkali Reserve in Normal and Tatho-

logical Individuals, /. Biol. Chem., 1917, xxxii, 499-507.
Pavy, F. W., (1) Researches on the Nature and Treatment of Diabetes, London,

1862.

(2) The Physiology of the Carbohydrates, London, 1894.

(3) Carbohydrate Metabolism and Diabetes, London, 1906.
Petersen, V. C. E., Von der Wirkung der " Kohlenhydrattage" in der Dia-

betesbehandlung, Deuisch. med. Woch., 1912, xxxviii, 1276-1278.
von Petteneofer, M., and Voit, C, Ueber den Stoffverbrauch bei der Zucker-

harnruhr, Z. Biol., 1867, iii, 380-444.
Petters, W., Untersuchungen iiber die Honigharnruhr, Vrtljschr. prakt. Heilk.,

1857, iii, 81-94.
PiORRY, Sur un nouveau systeme de medication employe avec succes dans le

diabete sucre, Compt. rend. Acad., 1857, xliv, 133-134. (Abstract.)
PiSKATOR, O., Ueber den Erfolg der Haferkur bei Diabetes mellitus. Inaugural

Dissertation, Giessen, 1912.
Popper, M.^ Das Verhaltnis des Diabetes zu Pankreasleiden und Fettsucht,

Osterreich Z. prakt. Heilk., 1868, xiv, 193-196. Ref. by Sauerbeck.

HISTORY 75

Potter, N. B., Cure de jeflne d'Allen pour le diabete sucr6, Ann. mid., 1917,

iv, 341-374.
Prasad, K., Experiences in Diabetes Mellitus in the East, Seventeenth Inter-
national Congress of Medicine, London, 1913, vi (2), (Medicine),

327-332.
Prout, W., On the Nature and Treatment of Stomach and Renal Diseases,

London, 1848.
Rathery, M. F., (1) Les pommes de terre dans I'alimentation du diabetique,

Bull, et mem. Soc. mid. h$p. Paris, 1911, xxxi, 160-173.
(2) De I'alimentation parmentiere dans le diabete. La Clinique, 1913, viii,

770-773.
Ratjlston, B. O., and Woodyatt, R. T., Blood Transfusion in Diabetes Mellitus,

J. Am. Med. Assn., 1914, Ixii, 996-999.
Regnault, v., and Reiset, J., Recherches chimiques sur la respiration des ani-

maux des diverses classes, Ann. chim. et phys., 1849, xxvi, 299-519.

Ref. by Lusk.
Reicher, K., Verhandl. deutsch. Kong. inn. Med., 1913, xxx, 179.
Reynoso, a., Memoire sur la presence du sucre dans les urines, et sur la liaison

du phenomene avec la respiration, Ann. sc. nat., 1855 (Zoologie), iii,

120-153. Ref. by Lepine.
Richardson, W., Remarks on Diabetes, London, 1871.
Richartz, H. L., Kohlehydratkuren bei Diabetes, Deutsch. med. Woch., 1913,

xxxix, 650^652.
RoBBiNS, C. P., Observations and Experiences of the Allen Treatment, J. -Lancet,

1917, xxxvii, 300-302.
RoLLO, J., (1) An Account of Two Cases of the Diabetes Mellitus; with Re-
marks, etc., London, 1797. Ref. in texts.
(2) Cases of the Diabetes Mellitus, London, 2nd edition, 1798.
ROLLY, F., Zur Theorie und Therapie des Diabetes mellitus, Deutsch. Arch. klin.

Med., 1911-12, cv, 494-521.
RosENPELD, G., Ueber die Entstehung des Acetons, Deutsch. med. Woch., 1885,

xi, 683-685.
Roth, N., Ueber Mehltage bei Diabetes, Wien. klin. Woch., 1912, xxv, 1864-1868.
ROTJBITSCHEK, R., and Gaupp, 0., Die Kohlehydrattherapie des Diabetes, Med.

Klin., 1913, ix, 1038-1041.
RuMPE, T., (1) Ueber die Assimilationsgrosse und den Eiweissumsatz beim

Diabetes mellitus, Berl. klin. Woch., 1898, xxxv, 945-948.

(2) Ueber Eiweissumsatz und Zuckerausscheidung beim Diabetes mellitus,

Ibid., 1899, xxxvi, 185-189.

(3) Untersuchungen iiber Diabetes mellitus, Z. klin. Med., 1902, xlv,

260-313.
Salomon, M., Geschichte der Glycosurie von Hippokrates bis zum Anfange des
19. Jahrhunderts, Deutsch. Arch. klin. Med., 1871, viii, 489-582.

76 CHAPTER I

Sauerbeck, E., Die Langerhansschen Inseln des Pankreas und ihre Beziehung

zum Diabetes mellitus, Ergebn. dig. Path. u. path. Anal., 2te Abt.,

1902, viii, 538-697.
Saundby, R., Diabetes Mellitus, in Allbutt and Rolleston's System of Medicine,

London, 1908, iii, 167.
ScHiFF, J. M., Untersuchungen iiber die Zuckerbildung in der Leber,' und den

Einfluss des Nervensystems auf die Erzeugung des Diabetes, Wiirz-

burg, 1859.
ScHU-LiNG, Inaugural Dissertation, Leipsic, 1911. Ref. by Joslin (2) and by

RoUy.
ScmEOKAUER, H., Haferkur und Blutzuckergehalt bei Diabetes mellitus, Berl.

klin. Woch., 1912, xlix, 1129-1132.
ScHMiTZ, R., (1) 4 Falle von geheiltem Diabetes und kurze Bemerkungen iiber

die Entstehung desselben, Berl. klin. Woch., 1873, x, 211-214, 222-

224.
(2) Kann der Diabetes mellitus ubertragen werden? Ibid., 1890, xxvii,

449-451.
ScHNEE, E., Diabetes, Its Cause and Permanent Cure, 1889, translation by

R. L. Tafel.
Seegen, J., Der Diabetes mellitus, Leipsic, 1870.
Senator, H., Ueber das Vorkommen von Diabetes mellitus bei Eheleuten und

die Uebertragbarkeit des Diabetes, Berl. klin. Woch., 1896, xxxiii,

665-666.
Severin, Kohlehydratkuren bei Diabetes mellitus unter besonderer Beruck-

sichtigung des Blutzuckers, Berl. klin. Woch., 1912, xlix, 2010-2011.
Spriggs, E. I., (1) Discussion on the Treatment of Diabetes Mellitus by Ali-
mentary Rest, Proc. Roy. Soc. London, 1915-16, ix, Therap. and

Pharm. Sect., 76-90. Also 63-76, (Leyton).
(2) The Fasting Treatment of Diabetes, Brit. Med. J., 1916, i, 841-845.
Stadelmann, E., Ueber die Ursachen der pathologischen Ammoniakausscheidung

beim Diabetes mellitus und des Coma diabeticum. Arch. exp. Path.

u. Pharm., 1883, xvii, 419-444.
Staubli, C, Beitrage zu Pathologie und Therapie des Diabetes mellitus, Deutsch.

Arch. klin. Med., 1908, xciii, 107-160.
Stengel, A., Diabetes, Progr. Med., June, 1915, 393-407; June, 1916, 426-440.
Stengel, A., Jonas, L., and Austin, J. H., The Treatment of Diabetes Mellitus

with Special Reference to Allen's Method, Pennsylvania Med. J.,

1915-16, xix, 283-287.
Stetten, De W., The Conservative Treatment of Diabetic Gangrene of the

Lower Extremity, J. Am. Med. Assn., 1913, Ix, 1126-1133.
Stillman, E., The Fasting Treatment of Diabetes Mellitus, with Special Reference

to Acidosis, Am. J. Med. Sc, 1916, cli, 505-515.

HISTORY 77

Stillman, E., Van Slyke, D. D., Cullen, G. E., and Fitz, R., Studies of

Acidosis. VI. The Blood, Urine, and Alveolar Air in Diabetic

Acidosis, 7. Biol. Chem., 1917, xxx, 405-456.
SxoKVis, B. J., Zur Pathologie und Therapie des Diabetes naellitus, Deutsch.

Kong. inn. Med., 1886, v, 125-159.
SxROUSE, S., (1) Diabetes in the Young, Med. Clin. Chicago, 1916, ii, 2, 327-338.
(2) Inanition in the Treatment of Diabetes Mellitus, Ibid., 1917, ii, 5,

999-1006.
Thomson, R. D., On the Digestion of Vegetable Albumen, Fat, and Starch, The

London, Edinburgh and Dublin Philosophical Magazine, 1845, xxvi,

322-328, 418-424. Ref. by Pfliiger.
TiEDEMANN, F., and Gmelin, L., Die Verdauung nach Versuchen, Heidelberg

and Leipsic, 1826-27, i.
Trommer, Unterscheidung von Gummi, Dextrin, Traubenzucker und Rohr-

zucker, Pharm. Centr., 1841, 762-764.
Trousseau, A., Lectures on Clinical Medicine, translated from edition of 1868

by J. R. Cormack, London, 1869, iii, 491-527, Lecture Ixiv, "Glyco-
suria: Saccharine Diabetes."
Tyson, J., A Treatise on Bright's Disease and Diabetes, Philadelphia, 1881 and

1904.
Van Slyke, D. D., and Cullen, G. E., Studies of Acidosis. I. The Bicarbonate

Concentration of the Blood Plasma; Its Significance, and Its Deter-
mination as a Measure of Acidosis, J. Biol. Chem., 1917, xxx, 289-

346.
Van Slyke, D. D., Studies of Acidosis. II. A Method for the Determination of

Carbon Dioxide and Carbonates in Solution, J. Biol. Chem., 1917,

xxx, 347-368.
Van Slyke, D. D., Stillman, E., and Cullen, G. E., Studies of Acidosis. V.

Alveolar Carbon Dioxide and Plasma Bicarbonate in Normal Men

During Digestive Rest and Activity, J. Biol. Chem., 1917, xxx,

401-404.
Van Slyke, D. D., Studies of Acidosis. VII. The Determination of /3-Hydroxy-

butyric Acid, Acetoacetic Acid, and Acetone in Urine, /. Biol. Chem.,

1917, xxxii, 455-493.
Van Slyke, D. D., and Fitz, R., Studies of Acidosis. VIII. The Determination

of /3-Hydroxybutyric Acid, Acetoacetic Acid, and Acetone in Blood,

J. Biol. Chem., 1917, xxxii, 495-497.
Walter, F., Untersuchungen Uber die Wirkung der Sauren auf den thierischen

Organismus, Arch. exp. Path. u. Pharm., 1877, vii, 148-178.
Warren, P., Two Cases of Diabetes Mellitus Treated with Opium, Med. Tr.

College Phys. London, 1813, iv, 188-225.
Waters, E. E., The Treatment of Diabetes by Alimentary Rest, Indian Med.

Gaz., 1917, Hi, 42-46.

78 CHAPTER 1

Watt, R., Cases of Diabetes, Consumption, etc., with Observations on the His-
tory and Treatment of Disease in General, Paisley, 1808.
Weichselbaum, a., (1) Ueber die Veranderungen des Pankreas bei Diabetes

mellitus, Sitzungsb. kais. Akad. Wissensch., 1910, cxix, 73-281.
(2) Ueber die Veranderungen des Pankreas bei Diabetes melitus, Wien.

klin. Woch., 1911, xxiv, 153-159.
Weichselbaum, A., and Stangl, E., (1) Zur Kenntnis der feineren Veranderungen

des Pankreas bei Diabetes mellitus, Wien. klin. Woch., 1901, xiv,

968-972.
(2) Weitere histologische Untersuchungen des Pankreas bei Diabetes

mellitus, lUd., 1902, xv, 969-977.
Weiland, W., Kohlehydratkuren und Alkalitherapie bei Diabetes mellitus; ihre

Indication und Prognose, Z. exp. Path. u.. Tkerap., 1912-13, xii,

116-151.
Weintraud, W., Untersuchungen iiber den Stoffwechsel im Diabetes mellitus

und zur diatetichen Therapie der Krankheit, Bibliotheca medica,

1893, Abt. D', No. I.
Werbitzki, F. W., Zur Frage des Einflusses der verschiedenen Kohlehydrate auf

die Glykosurie der Diabetiker, Z. exp. Path. u. Therap., 1909, vi,

235-253.
Williams, J. R., Recent Studies in Diabetes Mellitus, N. Y. Slate J. Med.,

1916, xvi, 412-418.
Williamson, R. T., (1) Diabetes Mellitus and Its Treatment, Edinburgh and

London, 1898.

(2) On the Treatment of Diabetes Mellitus with Casein and Cream, Brit.

Med. J., 1915, i, 456-458.

(3) The Treatment of Diabetes Mellitus, Lancet, 1917, i, 650-652.
Winternitz, W., and Strasser, A., Strenge Milchkuren bei Diabetes mellitus,

Centr. inn. Med., 1899, xx, 1137-1139.
WoLE, L., and Gutmann, S., In welcher Weise wirken Diatkuren auf das Ver-

halten des Blutzuckers bei Diabetikern? Z. klin. Med., 1914, Ixxix,

394^420.
Wolfe, W., Ueber Mehlkuren und Kartofielkuren bei Diabetes, If ed.^/iw., 1913,

ix, 789-790.
Woodyatt, R. T., (1) Prepared Foods and Diabetic Articles, Illinois Med. J.,

1909, xvi, 666-674.

(2) Discussion, Tr. Assn. Am. Phys., 1915, xxx, 339-340.

(3) Am. Sac. Advancement Clin. Investigation, 1915, Abstract of Proceed-

ings, 25-28.
ZiMMER, K., (1) Ein Beitrag zur Lehre vom Diabetes mellitus, Deutsch. Klin.,
1867, xix, 127-128, 133-136, 149-152, 160-162.

(2) Die nachste Ursache des Diabetes mellitus, Ihid., 1871, xxiii, 41-42.

(3) Der Diabetes mellitus, sein Wesen und seine Behandlung, Leipsic, 1871.

(4) Die Muskeln als Quelle des Zuckers im Diabetes mellitus, Deutsch.

Klin., 1873, xxv, 61-62.

CHAPTER II.
GENERAL PLAN OF TREATMENT.

This chapter, like the later ones, aims only to present the methods
and experience of the present investigation. A multitude of ques-
tions and details concerning the treatment of diabetes must neces-
sarily be left to general text-books on the subject. Discussion of the
observations and suggestions of others who have used this treatment
must also for the most part be omitted in the interests of brevity.
For details of the laboratory methods employed, reference may be
made to the original papers or to the excellent description in Joslin's
text-book.

As emphasized from the outset, every case of diabetes must be
managed according to its own requirements, and the best results are
obtainable only when the treatment is intelhgently individualized.
At the same time, a basic plan is essential, inasmuch as one general
principle underhes the treatment of all cases, and organization and
routine conduce to both ease and efl&ciency. The system developed
in this hospital may be described under the following headings:

I. General measures.

II. Treatment up to cessation of glycosuria in simple cases.

III. Complications and emergencies (acidosis, infections).

IV. Treatment following cessation of glycosuria.
V. Ideals of diet and laboratory control.

VI Practical management of diets.

79

I. General Measures.

A. The Routine Care of Patients.

1. Hospital Observation.^AH. the cases treated have been under
direct hospital observation. Between February 24, 1914, and July
1, 1917, altogether 96 patients were received, for a total of 165 ad-
missions, an average of 1.72 admissions to each patient. The great-
est number of admissions for a single patient was five. The total
number of days of diabetic treatment was 11,308, giving an average
of nearly 69 days to each admission. The longest single admission
was 304 days, the shortest a few hours (acute death). Hospital ob-
servation has seemed advisable for the following reasons: (a) to obviate
possible danger from acidosis during the active treatment of the dis-
ease by the fasting method; (b) to govern with the greatest possible
accuracy the individual diet, while the preliminary tests of tblerance
are being made, a ration built up, and its suitability demonstrated;
(c) for the instruction of the patient, in order that he may carry out
his diet and tests properly after leaving the hospital.

2. Confinement to Bed. — ^Unless made advisable by some complica-
tion or by a dangerous degree of acidosis, the patients have not been
confined to bed. Even during the most trying period of treatment,
namely the initial fast, it has not been uncommon for patients to lessen
the tedium of treatment by going to theatres, concerts, etc.

J. Clothing. — ^As many patients show a decided susceptibility to
cold weather, they have been advised to dress wannly, but without
specific instructions. The use of exercise, as discussed in Chapter V,
has obviated this condition to some ^tent, especially for that great
majority of diabetic cases which rank as relatively mild. But the
extremely low diets required for the very severe cases provide so
little combustible material that body heat must be conserved as care-
fully as possible.

4. Baths. — It has not been attempted to gain effect through hydro-
therapy. Bath temperature has been left to individual inclination.
Patients with severe diabetes have naturally chosen warm water.

80

GENERAL PLAN OF TREATMENT 81

5. Catharsis. — Chronic and obstinate constipation has been a rule
with few exceptions in the past history of these as of other severely
diabetic patients. It was regulated by cathartics before bran was
incorporated into the dietary of the hospital. This and the bulky
vegetables have almost banished constipation. When something
more active has been needed, the usual cathartics (castor oil, salts,
cascara sagrada) have been employed.

6. Medication. — The principle has been followed of giving drugs
to diabetic patients only as they would be used for other persons. No
medicines have been employed with a view to influencing the dia-.
betes, and no effect upon the diabetes has been observed from any of
those employed for incidental purposes. The recommendations of
various drugs in the past have probably been based upon inadequate
control and study of the cases. Special mention may be made of the
dangerous possibilities of anesthetics, especially chloroform. It is well
known that drugs of the chloroform class most easily injure the liver
when it is poor in glycogen. The visceral disturbances set up by
general anesthesia readily explain the production of either glycosuria
or acidosis, as so frequently described. The dangers are greatest
where the treatment is poorest, and the majority of diabetics under
thorough treatment are able to undergo suitable anesthesia without
glycosuria and without dangerous acidosis.

7. Complications. — The experience with these has not been large.
It is discussed in Chapter VII and in the individual case histories.
The treatment of the acute forms is described under Section III of
the present chapter. Metabolic complications in general do not in-
terfere with the treatment of the diabetes; the present diabetic diet
does not conflict, for example, with the usual treatment of nephritis.
In regard to infectious complications, it may be said that the ideal of
treatment is to make the patient as nearly like a normal person as
possible by means of diet, and then to use as nearly as possible the
measures considered best for normal persons. The recently debated
question of the relation of infections, sometimes focal and minor in
degree, to the etiology of diabetes is discussed in Chapter VIII.
Certainly bad tonsils, teeth, and other foci are sources of injury for
diabetic patients, which in acute attacks often give rise to glycosuria
and acidosis, and which may interfere seriously with the success of

82 CHAPTER II

dietetic treatment. It has been the policy with this series of cases to
have teeth or tonsils removed or other operations performed on the
same basis as advised for normal persons by conservative specialists.
Experience has indicated that such measures are beneficial from the
standpoint of the general health and also of the diabetes, in obviating
chronic and acute disturbances and the downward progress associated
with them. No patient has died or suffered harm from such opera-
tions performed while on the dietetic treatment, and it appears that
there is less danger from performing needed surgery than from
omitting it. On the other hand, if toxic absorption causes diabetes,
evidently the damage has mostly been done before the case has come
under treatment, for in no instance has the removal of a focus of in-
fection been followed by cure of the diabetes or by improvement
beyond that seen in other patients.

B. Ward Regulations and Clhstical Remarks.

1. Respiration, pulse, and temperature have been recorded at 4
hour intervals when fever was present or when acidosis or other
crisis threatened. Otherwise they have been taken every 12 hours.
Sohie of the information which may be gleaned from these signs in
diabetic patients follows.

Respiration. — Increased breathing is one of the classical indications
of acidosis, the increase generally applying to both volume and fre-
quency. Ordinarily it is a fairly constant and rehable index of danger,
unless obscured by the use of alkali; but in the type of acidosis pro-
duced by fasting, it may, like the drowsiness and other symptoms,
be far less prominent than in typical diabetic coma.

Pulse. — It may some day be possible to analyze the records of
these cases with respect to the pulse rate. F. G. Benedict has noticed
a relation between pulse and metabolism, and he and Joshn reported
acceleration of the pulse in proportion to increased metabolism in
severe cases of diabetes with active symptoms present. Patients in
the present series entering the hospital with intense diabetes and
threatening acidosis have regularly shown rapid pulse, which has
become slower under treatment. A few examples appear in tables in
certain of the case histories. Marked bradycardia has been observed

GENERAL PLAN OF TREATMENT 83

in some of the patients subjected to extreme undernutrition and the
corresponding reduction of metabolism, but this has not been con-
stant. The conditions are evidently not simple. On the one hand,
the tachycardia out of proportion to any possible exaggeration of
metabolism in impending coma is clearly an effect of intoxication upon
the circulation. On the other hand, Dr. Alfred Cohn has observed
in radiograms of some of these emaciated patients a diminution of the
cardiac shadow even out of proportion to the thinning of the chest.
This wasting of the heart muscle, like other states of general or circu-
latory weakness, might of itself alter the rate, especially in the di-
rection of tachycardia. With the uncertainty concerning the re-
spective influence of metabohc and other factors, a uniform inter-
pretation may be difficult.

Temperature. — It being understood that the temperature of diabetic
patients typically is normal, notice should be taken of variations in
two directions. Elevation of temperature often accompanies severe
acidosis, as illustrated in a few of the case records in this series.
Otherwise, fever of any grade generally points to infection, and ceases
with the finding and removal of the cause. Subnormal temperature
■^is common in proportion to malnutrition, whether the latter is due
to failure of assimilation of food with active diabetes, or to thera-
peutic restriction of diet. In the most severe cases of this series under
treatment, the rectal temperature has commonly been below 98° and
above 96°F. An important practical point is to watch the tem-
perature when children must be subjected to extreme xmdernutrition.
Even though the weakness is not visibly graver than before, a fall of
temperature to the neighborhood of 96-95°F. is a signal of danger,
which generally comes in time to permit warding off death by giving
food. If acidosis or stubborn glycosuria makes a full diet inad-
visable, even protein alone may support strength to the point where
fasting can be continued. More careful attention to this point
might possibly have prevented the fatal collapse which occurred in
several children of this series. The low temperatures in severely
diabetic patients are readily explained by the failure to receive or to
assimilate (according to the treatment) enough combustible material.
The same circxunstance may wholly or partly explain another im-
portant clinical phenomenon, namely the absence or diminished grade

84 CHAPTER n

of the febrile reaction to infection in some cases. Joslin called atten-
tion to the possibility of an almost complete lack of symptoms with
tuberculosis, even in an advanced stage. Something similar may be
witnessed occasionally with other infections. Either the weakened
individual is deficient in reactive power, or possibly the resultant of a
subnormal temperature and a febrile tendency may be something like
a normal temperature. This possible fallacy regarding fever should
be borne in'mind, and if a patient under rigid dietary control begins
to do badly without apparent cause, careful search should be made
for the infection which is often responsible.

2. Blood Pressure. — ^Aside from extraneous causes of hypertension,
the blood pressure of diabetic patients is generally normal or below
normal. Not only weakness, but also the intoxication of acidosis, is
responsible for the depression. Several patients received in extreme
stages have had a systolic blood pressure below 80, and in certain
others the circulation was so feeble that it was not possible to deter-
mine the pressure accurately. In such cases the question always arises
whether the patient can endure the week or more of absolute fasting
required to control his diabetes. In actual fact, every adult has
passed successfully through such fasting, not only without collapse,
but generally with more or less gain in strength, as indicated for one
thing by a rise in blood pressure. It thus appeared that intoxication
was the most dangerous factor in the depression, and relief from it
even at the price of fasting was necessary to save life. Therefore a
dangerously low blood pressure is not necessarily any contraindication
to fasting. On the other hand, it is possible that a fall in blood pres-
sure during fasting or extreme imdemutrition may be a signal of
danger, but the clinical observations have not been sufl&cient to show
whether this is a reliable warning or whether it comes in time to per-
mit of averting the danger.

3. Body Weight. — AU patients have been weighed naked each morn-
ing after voiding urine and before breakfast. The weight has been
recorded in kilograms. The weight is very valuable among the cri-
teria of treatment, though it is well known to be only a crude measure
of the true body mass. Patients with intense active diabetes some-
times seem to be dried out by diuresis; they may hold or gain weight
by water retention during fasting and for days or weeks on inadequate

GENERAL PLAN OF TREATMENT 85

diet thereafter. Fall in weight is sometimes sudden, to the extent of a
kilogram or two on a fast-day, without evident significance. Fat diet
following carbohydrate diet gives rise to such a water loss. The
commonest cause of precipitous fall in weight for a series of days is
acidosis. This melting away of weight and strength is seen in its
most alarming degree in the occasional cases combining intense acido-
sis, maximal D:N ratio, exaggerated nitrogen loss, and, with these,
rapid water loss. The opposite condition of sudden gain in weight
represents water retention, sometimes associated with relief from
glycosuria or acidosis, or with carbohydrate feeding, but frequently
from obscure cause. Even without nephritis, it is commonly con-
nected with salt retention and removed by salt-free diet. It may
differ in degree at different times and especially in different patients,
from invisible storage to extensive edema. Edema, sometimes huge,
has been well known in connection with the large salt intake in "oat-
meal cures," and especially with high dosage of sodium bicarbonate.
In Joslin's experience, water loss is one of the most dangerous, and
water retention or edema one of the most favorable conditions when
combating a dangerous acidosis. On the other hand, the more severe
cases have the greatest tendency to edema. This edema may there-
fore be classed among the indications of severity, though not aU
severe cases show the tendency equally. Apart from any mere
changes in the function of the kidney for salt, it is likely that there
is some unknown metabolic cause affecting the general tissues, either
belonging in some measure to diabetes itself, or perhaps largely or
wholly a phenomenon of undernutrition. It may possibly belong in
a series of dropsical conditions due to malnutrition, a related member
being the "hunger swelling" ^ of the wretchedly poor classes in Poland
on an almost exclusive potato diet in the present war, another re-
presentative being the "epidemic dropsy"^ of famine times in India,
another being the edema of cachectic children, while at the farther
extreme is beri-beri.

^Budzynski, B., and Chelkowski, K., abstracted in /. Trop. Med., 1916, xix,
141-42.

^Megaw, J. W. D., Indian Med. Gaz., 1910, xlv, 121; /. Am. Med. Assn.,
1911, Ivii. 826.

86 CHAPTER n

4. Measurement of Fluids. — It is well known and has lately been
emphasized by DuBois that an accurate water balance is one of the
hardest of all things to determine. In our cases the fluid intake and
output have been measured daily, and occasionally gross retention
or loss of water has been thus demonstrated. The information
afforded is necessarily vague and inaccurate. No allowance was made
for the water content of foods, and especially the large quantities of
vegetables generally given made this unknown factor a considerable
one. Most of the apparent discrepancies of intake and output
shown in the graphic charts are thus explained.

(a) Intake. — Thirst is not of abnormal degree in ordinary
diabetic patients under proper treatment, one of the advantages of
which is the relief from the discomfort of polydipsia and the incon-
venience of polyuria and nycturia. Severely diabetic patients on
very low diets generally drink rather freely, merely for the sake of
something to fill the stomach. There has been no need to restrict
fluids, except temporarily in a single patient (No. 1) who had formed
the habit of excessive drinking, and in a few others during periods of
marked edema. There is also no need to urge drinking of mineral
waters or anything else under the conditions of proper diet, there
being no poisons to wash out of the system. This may be an im-
portant advantage in cases with a complicating nephritis, with lim-
ited ability to excrete fluid. The one emergency which demands the
forcing of fluids to capacity is dangerous acidosis, as mentioned later
in this chapter.

(b) Output. — If an occasional patient drinks so little that the urine
is unduly concentrated, a troublesome turbidity may cloud the sugar
reactions; and instead of using chemical reagents for clearing, the best
plan all around may be to urge the patient to drink a normal quantity
of water. Usually in the severe cases the urine is very pale and clear,
both because of the excessive drinking stimulated by hunger and be-
cause of the small total content of solids. It thus resembles in appear-
ance the traditional diabetic urine, but a sharp difference is found in
the very low specific gravity. Delicate sugar reactions are easily
seen. The total 24 hour urine is saved in four separate portions each
day, the divisions coming at mealtimes. During all the earlier and
greater part of the investigation, days were counted from 7 a.m. of

GENERAL PLAN OF TREATMENT 87

one day to the same hour the next day. More recently, for general
hospital convenience, a change has been made to the less commenda-
ble method of counting from midnight to midnight. Accordingly
at present the order of periods is as follows:

Period I. Midnight to 7 a.m.
Period U. 7 a.m. to 11:30 a.m.
Period III. 11:30 a.m. to 5:30 p.m.
Period IV. 5:30 p.m. to midnight.

Two considerations favor this latter plan, namely that all urine is re-
corded under the date on which it was voided instead of being dis-
tributed over two dates, and second that the separation of days is
made at a time when there is little work in the hospital instead of at
the busy hour of 7 a.m. The arguments against this plan and in
favor of the former plan are more weighty, first that patients are sub-
jected to the inconvenience of being wakened at midnight to void
urine, and second that the urine of a day does not correspond cor-
rectly to the diet of the day, inasmuch as the break between days is
made at a time when the digestion of the last meal is not finished.
The segregation in four periods has a decided value. Patients are
not free from glycosuria unless the test is absolutely negative in every
period. Even when the reaction seems negative in the mixed 24
hour urine, tests of the separate specimens may show not only the
presence of faint traces but also after which meal they appeared.
Also a transgression of diet is sometimes revealed by a marked reac-
tion occurring suddenly in some period and clearing up thereafter,
whereas a slight reaction in the mixed 24 hour urine might be of doubt-
ful interpretation.

5. Meals. — Food has generally been served in three meals, with
sometimes an additional lunch at bedtime. In the past, minor pecu-
liarities in the relation between meals and glycosuria have been de-
scribed, generally glycosuria after carbohydrate ingestion and clear-
ing up during the night, more rarely glycosuria only at night, absent
during the day perhaps because of exercise. Also, it seems a promis-
ing plan to give carbohydrate distributed in nmnerous small fractions
at intervals, or in slowly digestible form, so as to avoid flooding

88 CHAPTER II

the system suddenly; and from such work as that of Thomas,'
it might appear that the best assimilation of protein would be ob-
tainable by the same scheme. Undoubtedly it is possible to flood the
system, especially with a quickly absorbable carbohydrate such as
sugar, when the same quantity in divided doses would be assimilated
without glycosuria. But under the ordinary conditions of diabetic
treatment, the essential cause back of either regular or irregular
glycosuria is a diet in excess of the tolerance or a persistently high
blood sugar. As for distribution of foods between meals, a mild case
of diabetes on a proper diet should be independent of such variations
within limits of reason. With severe cases, the difficulty lies in the
persistence of the hyperglycemia set up by either carbohydrate or
protein, so that before the effect of one ingestion has subsided the next
is superimposed upon it. In general, the total diet is the important
thing, and httle is to be hoped from unusual fractionation. A ration
so close to the verge of tolerance as to require such aid will not be
permanently tolerated. On the other hand, when the blood sugar
is kept normal by a total diet truly within the assimilative power,
glycosuria or other trouble does not result from any arrangement of
meals that is likely to be made.

6. Regulation of Habits. — Precision regarding diet has been the
chief essential. In other matters, it seems advisable, in brief, that
patients should do whatever is necessary to maintain the best possible
general health, while restraining their activities within the limits set
by their diet and tolerance. With a more hopeful general prognosis,
it becomes highly important to guard patients against alcohol and
drug habits; and especially as opium and other drugs are worthless
or harmful, and alcohol as a means of adding calories is also inadvis-
able, it is important that their widespread use in diabetic treatment
be stopped. With other indulgences, such as tobacco, tea, and coffee,
there are two opposite considerations. On the one hand, these articles
in excess probably injure all persons, and even in moderation appar-
ently injure some persons. On the other hand, the diabetic is denied
so many enjoyments in diet that it is a pity to deprive him of any
pleasures unnecessarily. Accordingly, the patients have been enjoined

* Thomas, K., Arch. Physiol, 1910, 249-285.

GENERAL PLAN OF TREATMENT 89

to use such moderation in these respects as is advisable for normal
persons. Smoking within careful limits has seemed very enjoyjtble
to men long addicted to it. All habitual users of coffee have derived
the utmost comfort from it, especially during fasting. From one to
three cups a day has been the allowance, and decaffeinized coffee has
been used if there was any suspicion of harm. In all other matters,
the usual life of the patient should be altered just as little and just as
much as demanded by the particular case. It will be seen that fre-
quently in this series men have continued business, children have at-
tended school, and everything possible has been done to keep patients
contented and useful. Especially those with milder diabetes are able
to pursue practically a normal existence with care only in diet, and
this fact is one of the most hopeful elements in the prognosis and one
of the greatest encouragements to fidelity in diet. Either mental or
physical overstrain is injurious to such a degree as to be out of the
question for the severest cases and inadvisable even for the milder
ones. Healthful rest, short of ennui, is important. Exercise is dis-
cussed in Chapter V. While reduction of weight and diet to a cer-
tain point is known to be compatible with physical and mental
efl&ciency, with more extreme diminution these are progressively im-
paired, until in the severest cases emaciation and invahdism are
chronic. Even in these worst cases, much depends on the individual
disposition, and light emplojonent or amusement aids in keeping the
mind off the subject of food. If it comes to a choice, neurasthenia is
preferable to overfeeding. Finally, one of the most important points
in the hygiene of diabetics is the avoidance of infections, either great
or small. This need not contraindicate outdoor exercise in cold
weather, which may be one means of building up resistance for pa-
tients who can stand it. For some, however, it means avoiding
crowds or any places where colds or influenza may be caught. For
others, it means the removal of foci of chronic or recurrent infection,
even at the risk involved in surgery. The best possible care of the
teeth, skin, and body in general is advisable at all times, though the
extreme susceptibility of diabetics to troubles from these sources is
greatly diminished under proper diet.

II. Treatment up to Cessation of Glycosuria in Simple Cases.

Any fixedly prescribed routine is opposed by the necessity of indi-
vidualizing treatment to suit the special needs of every case, and by
the desirability of free play for the physician's individuality and ad-
justment to environment. The basic principle of undernutrition
being grasped, the application can be made in various ways. This
period is occupied by the observation diet (if used) and the initial
fast.

A. The Observation Diet.

All sorts of possibilities are of course open in the choice of an ob-
servation diet. One conservative plan is to leave the patient for a
short time on as nearly as possible the same diet he has been taking,
to guard against the danger of any sudden change, especially in the
form of carbohydrate reduction. In order to establish data for com-
paring cases with one another and also with cases in the literature
treated by older methods, the majority of patients in this series have
been placed for a few days (2 to 5) on a diet somewhat as follows:

Protein per 24 hrs.

Carbohydrate per 24 hrs.

Fat per 24 hrs.

1.5 gm. per kilo.

10 to 25 gm.

Sufficient to bring total calories to 35 per
kilo body weight.

This is essentially the traditional "carbohydrate-free diet," for the
low carbohydrate allowance is given only in the form of green vege-
tables, such as have usually been included in diets of this description
in the past. With close laboratory and clinical observation, no hesi-
tation has been felt in placing patients abruptly on this diet; and
even though this was done in some very severe cases, such as No. 8,
the ability to control acidosis when necessary by fasting prevented any
mishap. This plan was necessary for the accurate study of the earlier
cases. Also, it frequently shortened the requisite period of fasting,

90

GENERAL PLAN OF TREATMENT 91

when the previous diet had been grossly improper. In general, it is
not therapeutically advisable, and was seldom used when the pa-
tient's condition at entrance seemed dangerous. More recently, this
observation period has been omitted, treatment has been begun im-
mediately, and the severity of the diabetes has been judged by the
subsequent progress and food tolerance.

B. The Initial Fast.

If diabetes is deficiency of the function of food assimilation, logi-
cally the most effective method of relieving strain upon this function
should consist in withholding food. The benefit of such relief should
apply not only to glycosuria but also to acidosis, irrespective of
whether the latter is wholly secondary to glycosuria or is partly a
specific diabetic phenomenon; and the slight ketonuria developed by
normal persons on fasting should not serve to confuse this expectation.

With regard to the initial tests on dogs, it may be mentioned that
irregularities in the glycosuria following total pancreatectomy are
well known, and in particular the urine may become free from sugar
just befort death from starvation or weakness; but the fatal diabetic
cachexia is always present and freedom from glycosuria never avails
to save the lives of such animals. Also, partially depancreatized dogs,
of the type best suited for therapeutic experiments, in the severest
stage continue to show glycosuria through the most prolonged fast-
ing, up to death or the hopeless exhaustion just preceding death. It
was a serious question whether the severest clinical cases are in a
similarly hopeless state, or whether they still correspond to the type
of dogs which can be freed from glycosuria by fasting and then kept
symptom-free at a more or less reduced weight by suitable regulation
of the total diet. Some encouragement was found in the results of
the shorter therapeutic fasts employed by former writers, but there
was nowhere in the literature any description of such a procedure as
contemplated, or any information as to what might happen if a pa-
tient with the worst type of diabetes were suddenly subjected to abso-
lute fasting until sugar-free. Accordingly, as noted in the history
of patient No. 1, the first attempt was made with considerable caution.
It so happened that this patient, although of the type in which glyco-

92 CHAPTER II

suria and acidosis had formerly been viewed as hopeless, and though
chosen as one in whom at least no great harm could be done, re-
sponded with rather exceptional ease to this treatment, and both
glycosuria and sjonptoms of impending coma quickly disappeared.
If this first experience had concerned a case, such as frequently en-
countered later in the series, requiring from a week to 10 days for
sugar-freedom, it is a question whether courage would have held out;
and if by any chance this first case had been one of the rare ones which
develop fatal acidosis on fasting, the proposed treatment might have
ended there. The first fact demonstrated was that even the severest
cases of human diabetes almost invariably become free from glycosuria
and as a rule also improve markedly as respects acidosis upon fasting.

Regarding the practical carrying out of the initial fast in ordinary
cases, the following details may be noted.

Water. — It is advantageous on general principles that the total
daily intake of fluids be at least 1500 to 2000 cc, and patients have
therefore been encouraged to drink tap water or any kind of mineral
or table water rather freely. In hot weather, cracked ice has some-
times been rehshed. No limit is placed on the fluid intake if patients
desire more than the above quantity.

Alcohol. — The use of alcohol was one of the early precautions
adopted to support strength during fasting. According to some earlier
literature, it not only produced no glycosuria but also might diminish
acidosis. In a number of cases, 50 to 350 cc. whisky or brandy
were given daily, in small divided doses every hour or two, the limit
for any individual being always short of producing subjective or ob-
jective symptoms. A rather general misapprehension was created
by the first papers pubhshed, as it was not clearly understood that
the use of alcohol was not new but was adopted entirely from pre-
vious writers, that it was used for cases with extreme weakness or for
other special purposes, and that it was never a primary or essential
feature of the treatment. Experience has tended to discredit it even
for the purposes for which it was first employed. It is a decided com-
fort during fasting to persons already habituated to its use. In other
persons, especially women and children, it often excites discomfort
or even nausea, and is therefore detrimental. It has an unmistakably
bracing action in weak patients, but its real effect is probably more

GENERAL PLAN OF TREATMENT 93

harmful than beneficial. Soup and coffee are preferable in almost
every case.

Soup. — In the great majority of cases, clear meat soup has been
allowed in quantities up to 600 cc. daily during fasting. The trivial
quantities of protein contained are harmless, but even such can be
avoided if desired by substituting beef extract. Soup is very com-
forting, and the fluid and salts may be valuable.

Coffee. — One to three cups of coffee or Kaffee Hag daily are pleasing
and supporting to most fasting patients. It is not advisable to
cultivate the coffee habit in children or other persons not addicted
to it.

Solids. — Three to six of the bran muffins described subsequently in
this chapter have generally been allowed daily during fasting. They
are of some use in diminishing the feeling of emptiness. Theoreti-
cally, small quantities of thrice cooked vegetables might be permissi-
ble in the milder cases, but have very seldom been used, because there
is no use in trying to trick the appetite too far, and it is better for
patients to learn to bear rigorous fast-days.

Purgation. — The habitual constipation of most diabetics renders a
cathartic advisable at the outset. With the use of bran, there is
generally more natural tendency to defecation. On a prolonged fast
with only fluid intake, the patient may safely go for a week or more
with no bowel movement. There is no specific virtue in purgation.

Edema. — ^As mentioned, water retention even to the point of visible
edema is sometimes observed in fasting, especially in the more severe
cases. It seems never to have been reported in normal persons on
simple fasting, but only in connection with prolonged malnutrition
and abnormal living. Diabetics vary in susceptibiUty, but the imme-
diate cause of edema is usually the salt of the above ingesta, especially
the soup. No harm has ever been observed from the fluid retention.
The prevention or remedy consists in the restriction or exclusion of
salt.

Comfort and Strength. — Fasting, sometimes up to a month or more
in duration, has been a well known practice for purposes of metabolic
studies and sometimes for public exhibitions, and the subjects have
retained physical and mental powers through these long periods and
have denied any real suffering. Fasting has also been one of the com-

94 CHAPTER n

monest religious customs of numerous peoples and sects. On the other
hand, the omission of a single meal is often felt as a great privation,
and a few days' abstinence from food is viewed as something serious
and alarming, not only by people in general but even by numerous
physicians. The most profoundly emaciated and cachectic diabetic
patients undergo even a 10 day fast with ease and safety. The re-
fusal of a patient to undergo fasting is generally as much the fault
of his physician as of himself, provided he is of a type who
will faithfully carry out any kind of careful dietetic treatment. The
first fast generally dispels the dread, and furthermore is valuable for
discipline.

As described in the histories, the fasting treatment has been applied
to patients in all physical states, from those appearing in full health
and strength to those seeming at the point of death from weakness and
emaciation. The effect upon the immediate comfort has varied with
individuals. Some patients have entered with nausea or vomiting
which prevented eating; others rejoiced in quick relief from acidosis
symptoms; others had been overfed till fasting was agreeable in itself.
At the other extreme are the occasional patients who, whether in
good or poor health and flesh, feel weak, uncomfortable, and depressed
whenever they fast. In the intermediate position are the great ma-
jority of patients, who find fasting more or less inconvenient but no
serious hardship, and who carry on their usual activities or amuse
themselves in various ways during either long or short fasts. As
stated elsewhere, some very weak patients have unmistakably gained
strength on fasting. More or less decline in strength is the rule.
Even in the most extreme cases, no adults have died from weakness
either during or within any short time after fasting to sugar-freedom.
Two small children (cases Nos. 45 and 71) entered with such a com-
bination of extreme diabetes, acidosis, and weakness that the choice
between coma and starvation could not be avoided; and it is conceiv-
able that such a dilemma may be possible in very rare adult patients.
The use of levulose as a restorative in sudden collapse of strength is
illustrated in cases Nos. 4 and 45.

Laboratory Control. — ^Laboratory tests are qualitative and quanti-
tative. So much information is derivable from the former that it is
generally possible to carry through a fast successfully by their guid-

GENERAL PLAN OF TREATMENT 95

ance alone. The qualitative test for urinary sugar has been the key-
stone of the plan, since fasting is terminated on the day after it
becomes negative. Acidosis can also be judged fairly safely by the
increase or diminution of the ferric chloride test of the urine and of the
Rothera test applied to the blood plasma (Wishart),and by the acid or
alkaline reaction of the urine; by simply noting the dosage of alkali
required to turn the urine alkaline, the latter test acquires a quantita-
tive significance Also, in default of accurate measurements of blood
alkalinity, the test proposed by Yandell Henderson* should not be
overlooked; namely, that normal persons can hold the breath 30 or
40 seconds without specially deep preparatory inspiration, but that
this period diminishes somewhat in proportion to the reduction of
blood alkali.

Of quantitative tests, that for blood sugar is of minor practical im-
portance during the fast. Generally the blood sugar falls; sometimes
it rises at first even when glycosuria is diminishing and the general
condition improving; and in the rare cases where fasting results badly,
the persistence or increase of hyperglycemia may be one significant
feature; but other tests are more important danger signals. Also,
the quantity of sugar excreted in the urine is of little practical im-
portance in the great majority of cases, though persistence or increase
of glycosuria gives warning of the failure of fasting, and likewise of
the danger of coma even independently of direct acidosis tests.

Quantitauve nitrogen determinations are of significance for the ra-
pidity of protein destruction and the D : N ratio, which is an im-
portant index of severity. Increase of the quantity of amino-acids in
blood and urine also marks the severe cases.

Possibly some significant behavior of the blood fat may later be
found, but at present such analyses have no established value as a
guide for treatment at this stage. In dogs it seems probable that
fasting acidosis is sometimes accompanied by increased lipemia, but
in human patients fasting generally produces no increased turbidity
of the plasma.

The essential danger that threatens during fasting is acidosis, there-
fore the tests for it are preeminent. All analyses of the urine are un-

* Henderson, Y., /. Am. Med. Assn., 1914, Ixiii, 318.

96 CHAPTER n

reliable. Very high excretion of acetone bodies is dangerous, but yet
the progress may be favorable; while lower excretion may indicate
either less acidosis or more dangerous retention. The urinary am-
monia is governed not only by the degree of acidosis but also by
other factors such as the total nitrogen output and the alkali dosage.
The recently developed blood tests are the most convenient as well
as the most trustworthy. The Van Slyke method' of determining
the C02-combining power of the blood plasma has been used in the
present series of cases, because of its combination of ease and accu-
racy. Methods showing the carbon dioxide tension of the alveolar air°
are simple and almost equally reliable. Those requiring the patient's
cooperation encounter difficulty in coma or similar states, and even
the bag or mask methods are subject to possible errors from circulatory
or other causes. The air analyses are specially useful to those de-
siring to avoid the taking of blood, but both physicians and patients
should learn that blood ought to be taken for various analyses as a
means of intelligent diabetic treatment. The hydrogen ion concen-
tration of the blood, determined by either the gas-chain method, the
oxyhemoglobin dissociation, or the more convenient procedure of Levy,
Rowntree, and Marriott,' has recently attracted attention clinically as
well as experimentally, but is not so early or delicate an indicator of
danger as the CO2 capacity. Quantitative analyses for acetone bodies*
in the blood may sometimes be of practical service. For example, if
high and increasing, they may give warning of impending coma, even if
this is not revealed by any of the above mentioned tests. On the
other hand, the danger in different diabetic cases by no means runs
parallel to the ketonemia, neither has any infallible index yet been
derived from the relative proportions of /3-oxybutyric and acetoacetic
acids.

In summary, therefore, all laboratory tests are open to more or less
fallacy. The more tests performed, the more easily and accurately
can the condition be judged and needful measures instituted. If it

6 Van Slyke, D. D., and CuUen, G. E., J. Biol. Chem., 1917, xxx, 289.
^ Fridericia, L. S., Bed. klin. Woch., 1914, li, 1268. Marriott, W. M., J. Am.
Med. Assn., 1916, Ixvi, 1594.

' Levy, Rowntree, and Marriott, Arch. Int. Med., 1915, xvi, 389.
* Van Slyke and Fitz, J. Biol. Chem., 1917, xxxii, 495.

GENERAL PLAN OE TREATMENT 97

comes to a question of the absolute minimum of laboratory work on
which fasting can justifiably be conducted, the methods of choice are
the Benedict qualitative sugar test for the urine and the Van Slyke
determination of the bicarbonate reserve of the blood plasma, together
with the nitroprusside reaction in the plasma.

III. Emergencies and Complications.

A long list of greater or lesser troubles associated with diabetes
might be enumerated here. As mentioned in Chapter VII, the pres-
ent experience indicates that these traditional complications, which
have been the cause of so much suffering and fatality in diabetes, are
for the most part avoidable under efficient treatment; and when al-
ready present, it is beUeved that the best and quickest means of
curing any of these or hindering their further advance lies in fasting
followed by restriction of the total diet as described. A physiological
condition which stands as a real complication in the management of
diabetes is pregnancy. It was encountered in only one instance in
this series, namely case No. 38, where it was associated with a hope-
less complex of infections. JosUn's experience has proved that the
formerly grave prognosis for both mother and child can now be much
brighter; and unless deterred by eugenic considerations, the possi-
bility exists for women with not too severe diabetes to go through
pregnancy successfully. The essential requirement is the same
thorough dietetic treatment as for other patients. By far the chief
emergencies or complications, however, which are liable to be en-
countered in undertaking the fasting treatment, are acidosis and
infection.

A. Acidosis.

1. Definition.

If the normal resting metabolism upon which calorimetric studies
are based be accepted as a standard, acidosis may be broadly defined
as any departure from this normal tending to turn the reaction of the
body to acid. It may thus include all possible states of increased
production or deficient destruction of acid, administration of acid,
retention of acid, or deficient supply or abnormal loss of bases. The
most important clinical type of acidosis is a ketosis; namely, the
occurrence of abnormal quantities of the so called acetone bodies —

98

GENERAL PLAN OF TREATMENT 99

whether due strictly to excessive formation or deficient utihzation is
uncertain. Therefore, in accordance with Naunyn's dictum, acidosis
is present in diabetes whenever an abnormal increase of acetone sub-
stances is demonstrable in the urine or blood. Attempts to replace
this metabohc or biological definition by purely chemical conceptions
of alteration of reaction, derived from experiments in vitro, have
thus far been scientifically fallacious, on grounds which need not be
reviewed here, and clinically are open to the following objections:
(a) these changes represent no independent phenomenon, but only
some late stage of a process which should properly be regarded as a
unit from beginning to end; (6) the striking abnormal production of
acid in the protoplasm, perhaps up to 100 gm. of /3-oxybutyric acid
daily, is the essential disorder to be defined, and the mere neutraliza-
tion of the products by alkali cannot properly be regarded as abolish-
ing this biological acidosis; on the contrary, the necessity of amimonia
formation or alkah dosage to maintain neutral relations should in it-
self be considered evidence of acidosis; (c) the therapeutic point of the
whole matter is that attempts to treat by neutrahzation of products
are often illusory and sometimes dangerous even as temporary meas-
ures, and lead always to failure in the end, while successful treatment
can only consist in stopping the abnormal acid production which is
the essential disturbance.

2. Fasting and Undernutrition Txeatment in Various Types.

The ordinary acidosis of severe diabetes is no contraindication to
beginning a fast, and, as already stated, typically diminishes pro-
gressively during the fast. The more severe the acidosis, and the
more imminent the impending coma, the more urgently is fasting de-
manded, so that the patients of this series who have entered in the
most dangerous condition have been placed immediately on strict
fasting. The results have been favorable, as shown in Chapter VII.

In the milder cases of diabetes, including those previously free from
acidosis, some degree of ketonuria, generally shght, sometimes rather
heavy, may develop during fasting, without danger or any need for
changing the fasting program. Exceptionally, however, in cases in-
herently either mild or severe, blind persistence in fasting may result

100 CHAPTER II

in dangerous or fatal acidosis, as happened in one case (No. 30) in the
present series. This difficulty, though exceptional, is certain to be
encountered if any considerable nimiber of cases are treated; and the
fact that it had not formerly been known is one evidence of the
newness of the fasting method.

This atypical behavior may sometimes be expected in middle-aged
or elderly patients, who have carried their diabetes for possibly 5
to 15 years with little or no apparent harm, whose glycosuria may be
heavy or moderate, whose acidosis may be chronic but slight, and
whose bodily state may be that of good nutrition or slight obesity.
Such a case may appear very promising for quick and gratifying re-
sults. During the fast, glycosuria may persist or diminish; keto-
nuria is generally qualitatively heavy, but quantitatively may not
be great, especially if alkali is not given. What is seen clinically is
first a vague malaise, often with headache or pains elsewhere, dizzi-
ness, and increasing prostration. Nausea seems to be invariable, and
the gravest stage is when vomiting is established. Though the con-
dition is acidosis, the appearance is not that of t3^ical coma.
Dyspnea may not be prominent, and the consciousness may be clear
up to the last hours or minutes of lif^. The end comes with uncon-
trollable vomiting and profound and rapidly progressive weakness.

Treatment in this final stage offers little hope. Glucose or levulose,
orally, rectally, subcutaneously, or intravenously, should theoretically
be most important, provided the diabetes is inherently mild enough to
permit any effective utilization. A few patients elsewhere are said
actually to have been saved by such means. If food can be taken at
all, whatever protein-carbohydirate diet promises to be best retained
is indicated. The use of sodium bicarbonate is customary; it is prob-
ably best given intravenously, possibly by rectum, to avoid nausea.
If carbohydrate or protein as above described succeeds in arresting
the underlying intoxication, it is possible that the cautious use of
bicarbonate may guard against death from simple deficit of alkali
and thus .may be a temporary assistance in tiding over the crisis.
The traditional large doses of alkali are dangerous. If the other
measures fail to arrest the underlying toxic process, alkali, in any
dosage is useless, and the patient dies just as certainly whether the
blood alkalinity is low or high.

GENERAL PLAN OF TEEATMENT 101

The essential treatment lies in prevention, and with simple care
these unnecessary accidents can be avoided. For this purpose, Joslin
has introduced a precautionary program, which, briefly, consists first
in omitting fat from the diet, then gradually diminishing protein and
finally carbohydrate, down to complete fasting unless glycosuria ceases
before. This is opposite to the orthodox treatment of a few years ago,
which started with a gradual reduction of carbohydrate. The plan
is theoretically sound, embodying the same general principle of under-
nutrition which underlies all this treatment. Besides the usual loss
of a little time, there is an imaginable disadvantage in very rare cases,
which might be controllable by immediate fasting but within a few
days might be advanced past hope; also it is a possible question
whether a threatening acidosis may ever be aggravated by food of
any sort, even protein and carbohydrate. The only concrete ob-
servation is in case No. 55 of this series, where it must be confessed
that the diet which made trouble on November 5 did contain an
appreciable quantity of fat. In favor of the gradual procedure are
the following considerations: first, in Joslin's experience, which is
larger than any other, dangers such as here suggested have not actu-
ally been met; second, the duration of the initial fast is shortened;
and third, the occurrence of fasting acidosis has been entirely pre-
vented. This modification has therefore been widely adopted and
will doubtless continue in extensive use. Though Joslin's own cases
are studied by complete laboratory methods, the modified treatment
becomes more important in proportion as laboratory control is lacking.

As already stated, the method of immediate fasting has been em-
ployed in the whole of the present series. Since the early experience
(case No. 30) calling attention to the occasional danger, it has been a
simple matter by combined clinical and chemical observation to avoid
further mishaps. The practical management of dangerous cases of
acidosis may be discussed according to the three classes into which
they fall.

(a) Typical Coma. — ^Patients in actual deep coma generally die.
The considerable proportion of recoveries in this series shows that
treatment is not entirely useless. With coma impending but not yet
complete, death was the usual outcome under former methods, but
under fasting treatment the usual outcome is recovery. It is be-

102 CHAPTER II

lieved that immediate fasting, with the adjuvants mentioned below,
is the safest general rule for cases of threatened coma. Generally the
improvement is quick, and may be evident within twenty-four hours
or less. Sometimes the patient may appear more stuporous on the
second day than on the first, and the blood alkalinity may be almost
stationary or may even fall a little. In all the favorable cases seen,
there has been unmistakable improvement by the third day. It is
worth noting that cases of ordinary coma, coming on in the usual
manner on any kind of diet, have never shown injury from fasting;
i.e., fasting acidosis has not developed where the threatened coma was
due to feeding. The patients whom inexperienced physicians are
likely to be afraid to fast are the ones who usually need fasting most
and who usually show the most striking benefits.

(&) Fasting Acidosis. — ^As stated, occasional patients, in no imme-
diate danger of coma on whatever diet they may be taking, react to
fasting with an increase of acidosis, sometimes to dangerous degree.
The reason for this pecuharity is unknown, and there is also no known
way of foreteUing which cases will exhibit it. Examination of the
case records in this series will show that neither the mildness or severity
or duration of the diabetes, nor the initial degree of acidosis, nor the
intensity or persistance of glycosuria, nor the store of reserve fat
represented by obesity or emaciation, nor the supply of circulating
fat as represented by lipemia, necessarily stands as a determining
factor. The same patient at different times may behave oppositely.
Thus, several cases in this series displayed more or less tendency to
fasting acidosis at first, while at subsequent periods they reacted to
fasting with the usual decrease of acidosis. The essential treatment
for fasting acidosis is food; and the only known rule of procedure up
to the present is if a patient develops acidosis on feeding to fast
him, and if he develops acidosis on fasting to feed him. The kind of
food seems to be of subordinate importance. Thus the fasting acido-
sis symptoms of patient No. 35 ceased entirely on an orthodox protein-
fat diet, which represents the surest means of producing acidosis in
most patients. Nevertheless, it should not be considered that the
choice of diet is immaterial. Fat is theoretically disadvantageous.
Carbohydrate may be beneficial if the diabetes is not too severe, but
should be closely lunited to avoid too great hyperglycemia and gly-

GENERAL PLAN OF TREATMENT 103

cosuria. Protein is on general principles the most valuable food, and
either alone or with such carbohydrate as may seem advisable, it
makes up a low caloric diet which both relieves fasting acidosis and
at the same time continues the benefit of undernutrition. After a
few days of feeding, a second fast is generally well borne, and both
glycosuria and acidosis are brought under control as usual. After
thorough and successful treatment, all patients become able to
undergo fasting without danger from acidosis.

(c) Indistinctly separated from the above two groups are the occa-
sional examples of extraordinary intensity. Some cases of diabetes
almost from the outset, and others after a longer or shorter course of
ordinary symptoms, reach this degree characterized by maximal dex-
trose-nitrogen ratios, enormous protein breakdown, high amino-acid
values in blood and urine, and extremely threatening acidosis. Unless
further improvement in the treatment is devised, probably a majority
of such patients will continue to die, as did several in the literature,
and patient No. 39 in the present series. Some of them apparently
represent a degree of diabetes which is uncontrollable by fasting,
perhaps because fasting is not sufficiently potent to check the rush of
metabolism. There are three favorable considerations in regard to
this condition: first, though famiHar in dogs, it is rare in human pa-
tients; second, it is sometimes controllable by skillful treatment;
and third, a distinction exists between intensity and severity, for
if it is possible to weather the immediate storm of symptoms, these
extremely intense cases sometimes turn out later to be less severe
than anticipated. Thus, the patient of Geyelin and DuBois gained
a tolerance running into hundreds of grams of carbohydrate, and the
patient of Jonas and Pepper seemingly recovered from his diabetes
altogether. In Chapter VIII it is shown that the distinction rests
upon the apparently functional nature of the chief disturbance un-
derl3dng the intense symptoms, while anatomic destruction of the
islands of Langerhans, which is the fundamental basis of true severity,
has not necessarily advanced very far in these cases. As regards
acidosis, it may be assumed as a general principle that if fasting does
not control glycosuria the result will be coma. These cases differ from
those of group (b), which somehow react unfavorably to fasting irre-
spective of the presence or absence of glycosuria. The fatal acidosis

104 CHAPTER n

from prolonged fasting in the present group seems to occur only be-
cause of the persistence of high glycosuria. Successful treatment has
consisted in replacing fasting by an undernutrition diet of carbo-
hydrate or protein. Carbohydrate may be helpful for diuresis, but
with a maximal D:N ratio its value otherwise is questionable.
Protein offers theoretically the greatest advantages, in that it fur-
nishes carbohydrate and urea for diuresis and ammonia for neutral-
izing acids, and at the same time is the most important food for
maintaining strength and protecting body nitrogen. Successful
treatment with carbohydrate and protein is illustrated by the cases
of Geyelin and DuBois and Jonas and Pepper above mentioned.
Success with pure protein diet is illustrated by case No. 37 in this
series. This boy had first entered the hospital with impending coma
which had developed on a mixed diet and which cleared up smoothly
on fasting. In a relapse 11 months later, he was readmitted with gly-
cosuria which had resisted 8 days of fasting and acidosis which
threatened early coma if fasting were continued. By a practically
pure protein diet for 10 days, the acidosis and other symptoms were
relieved, and then glycosuria was easily abolished by fasting. As
mentioned, in some cases fasting, feeding, alkali, and all other measures
are unavailing, and here death occurs from acidosis or exhaustion
within a few days. Obviously, all cases of this group should be under
the care of the most experienced specialist available.

3. Adjuvant Measures and Remarks.

(o) Emptying Alimentary Canal. — ^When it is known that food has
been recently eaten, lavage of the stomach is advisable in impending
coma, and if there is any doubt, it is a wise precautionary measure.
Joslin makes it a routine for children with dangerous acidosis. It is
also important to empty the intestine thoroughly by a combination
of any vigorous purgative and high colonic irrigation. There may be
some incidental benefit from absorption of saline solution if this is
used for the colonic injections, or of. alkali if the irrigation is per-
formed with sodimn bicarbonate solution. Case No. 25 illustrates
the great difl&culty of securing adequate intestinal evacuation in some
instances, and also its importance.

GENERAL PLAN OF TREATMENT 105

(b) Drugs. — Except in accidental emergencies, it is doubtful if drugs
ever rescue patients from acidosis. Such an emergency is shown in
case No. 11. This patient was not actually saved; but if there is
cardiac and renal failure along with acidosis, it is evidently possible
that life may be preserved by medicines which restore circulation and
excretion. When any patient is sinking into. the stupor of ordinary
coma or the weakness of fasting acidosis, there is always the incli-
nation to stimulate heart, brain, and kidneys by such drugs as caf-
feine and digitalis, if only in the hope of supporting strength until
other measures have time to take effect. The liberal use of coffee, as
illustrated in a few cases in this series, may be of some slight service.
But whether employed early or late, drugs are probably never able to
change the result in uncomplicated cases. • If a large dose of alkali is
given intravenously, there is a possible question whether some circu-
latory stimulant might be of value for guarding against the sudden
death which sometimes follows within a few hours.

(c) Sugars. — Glucose and levulose have received long and extensive
trial as weapons against acidosis in the past. Their promise of use-
fulness is greatest in fasting acidosis, at the stage when all ordinary
food is vomited. They may then be given, preferably in 5 per cent
solution, rectally, subcutaneously, or intravenously. For the latter
purpose, a slow continuous infusion by some such device as that of
Woodyatt' appears obviously best. For ordinary coma, sugar might
have some value as a diuretic, and also for diminishing the formation
of acetone bodies if it can be burned. But as a rule, the blood sugar
is already undesirably high, and little if any sugar can be metab-
olized. It is well known that the attempted sugar treatment of coma
has in general been such a failure that it has been abandoned by the
best authorities. Von Noorden^" found absolute fasting more effective
than levulose, milk, or oatmeal for coma. Anything that aggravates
the diabetes and delays the clearing up of glycosuria may possibly
act injuriously also upon the acidosis. For these reasons it is be-
lieved that as a rule sugar or carbohydrate should not be used for the
treatment of ordinary cases of acidosis.

' Woodyatt, /. Biol. Chew,., 1917, xxix, 355-365.
'" von Noorden, C, Zuckerkrankheit, 1912, 388.

106 CHAPTER n

{d) Alcohol. — So far as observable empirically, alcohol has shown
no specific value in connection with acidosis. Some experiments to be
published later agree with the finding of Higgins, Peabody, and Fitz"
that it tends rather to increase acidosis. One objectionable feature
is its frequent nauseating effect. For these reasons, the use of
alcohol is considered inadvisable even for weak patients with serious
acidosis.

(e) Salts. — The value of inorganic salts and the danger of extreme
loss of salt have been emphasized especially by Joslin. Sodium
chloride is valuable as a diuretic; also, its retention is associated with
edema, and only one patient with edema in Joslin's experience has
ever died in diabetic coma. Therefore sodium chloride may be ad-
ministered by mouth in quantities up to 20 or 30 gin. daily unless
prevented by nausea or other contraindication; physiological saline
solution also is useful, by rectum, subcutaneously, or intravenously,
for conveying salt as well as fluid. In case No. 1 and a few others,
trial was made of giving also salts of potassium, calcium, and mag-
nesium, with a view to physiological balance, but no apparent advan-
tage has been found in this plan over the use of sodium salts alone.
Soup is valuable partly for the salts it contains.

(f) Fluids. — As already mentioned, the conduct of fasting with
ordinary moderate acidosis calls for only moderate quaritities of
hquids. On the other hand, the largest practicable fluid supply is
one of the most essential matters in the treatment of threatened
coma. Authorities from Rumpf to Joslin have recognized the
danger of desiccation of the body, especially with the vomiting which
occurs so frequently. The further use of fluids is to promote the
freest possible diuresis. Joslin set the standard of 10 liters a day
when possible. If the patient can drink and retain sufficient liquid,
it need not be given in other ways. The patient should be persuaded
to take water as much and as often as possible, either hot or cold, and
free use should also be made of coffee, tea, soup, cracked ice, or what-
ever else will aid in introducing fluid and perhaps also in preventing
nausea. If drinking is insufficient — for example, if an adult with im-
pending coma cannot retain 5 liters per day — recourse may be had to

" Higgins, H. L., Peabody, F. W., and Fitz, R., /. Med. Research, 1916, xxxiv.
263-272.

GENERAL PLAN OF TREATMENT 107

corresponding quantities of 0.85 per cent sodium chloride solution by
rectum, subcutaneously, or intravenously. From 500 to 1000 cc.
salt solution at a dose intravenously is considered by Joslin often
preferable to alkali, because less dangerous. Here again the Wood-
yatt injection apparatus might be advantageous. The reasons for
the importance of keeping up copious diur-esis by fliiids are the fol-
lowing. First, the possible concentration of acetone bodies in the
urine is limited (the highest observed by Fitz was between 9 and 10
gm. per liter); for this reason the excretion can often be multipHed
by almost as much as the quantity of urine is multiplied, and large
quantities of dangerous material thus removed. A high excretion,
e.g. 50 gm. or more of total acetone bodies daily, is never possible ex-
cept with abundant diuresis. Second, /3-oxybutyric and acetoacetic
acids circulate in the blood only in the form of salts. They are partly
eliminated as salts, but also to an important extent the kidney saves
the base for the body and excretes the free acids. Through this saving
of base by the acid-secreting power of the kidney, the administration
of fluid is equivalent in some degree to the administration of alkali,
without the special disadvantages or dangers of the latter.. .

(g) Laboratory Guidance. — Mention has already been made of the
various routine tests for acidosis, and preference expressed for the
Van Slyke plasma bicarbonate method. More reliance can be
placed upon the blood alkalinity, determined by this or by one
of the less direct methods, than upon any other single feature of the
condition, and without this information it is often impossible in
critical cases to judge progress or direct treatment intelligently.
With any serious degree of acidosis, estimation of the bicarbonate
reserve should be made once daily. In acute danger, such analyses
are sometimes demanded at frequent intervals, perhaps once every 4
hours, to indicate whether the response to treatment is favorable or
whether a change should be made. At this stage, the greatest service
of this test is to give warning of an increase of acidosis on fasting,
often before clinical symptoms make this evident, and in time to avert
the danger by giving food. As an arbitrary ground plan for apply-
ing the results of this test, the scheme in Table I may be suggested.
Nevertheless, clinical judgment and experience are important in
deciding whether unfavorable progress calls for a reversal of treatment

108

CHAPTER II

or for more rigorous adherence to the same plan. There is ample
evidence in the present series of cases that neither this nor any other
single test can be followed blindly as an infallible guide. Irregularities
are sometimes marked, even in absence of extraneous modif)dng factors.
Thus, patient No. 63 showed the lowest CO2 capacity in the entire
series (12.3 per cent), yet recovered promptly, whereas other patients
died although their bicarbonate reserve was by no means so low.
Patient No. 35 developed malaise, nausea, and drowsiness on fasting,
and the observers were convinced that unless fed he would have died
in the typical intoxication. The CO2 capacity was within normal
limits even without alkah dosage. Probably it would have fallen
at a later stage; but the significant facts are that the clinical symp-
toms alone gave warning in time to permit effective treatment, that

TABLE I.

Degree of acidosis.

Plasma COj.

Further drop of COz pennitted before interrupting fast.

vol. per cent

—

Above 53 .

To 45 volume per cent.

Mild.

53-40

Drop of 10 to 5 volume per cent.

Moderately severe.

40-31

(t (c 3 <( 2 " " "

Severe.

Below 31.

Fast interrupted in 6 to 12 hrs. unless CO2 rises
with fasting and alkali.

theintoxication symptoms increased when sodiumbicarbonateproduced
an actual rise in the CO2 curve, and that feeding cleared up the sjonp-
toms even though the CO2 capacity was slightly lower on certain subse-
quent days than at the time of the intoxication. Such discrepancies and
irregularities, spontaneous in origin, are much less numerous than those
resulting from alkaU therapy. Thus in case No. 30, a typical ex-
ample of acidosis with fatal result on fasting, the plasma bicarbonate
was forced up within normal limits by alkali dosage while well marked
intoxication was present, and the last reading, with severe and hope-
less intoxication existing, was 45 per cent, which falls within the limits
of "mild" acidosis according to the above table. Patient No. 45
had before admission been kept saturated with huge doses of sodium
bicarbonate. He' entered almost in coma, typical except, for absence
of hyperpnea, notwithstanding the CO2 capacity of 73.5 volume

GENERAL PLAN OF TREATMENT 109

per cent in his plasma. In full coma on September 9, the CO2 ca-
pacity was 84.9 volume per cent, i.e. abnormally high, and higher than
on other occasions without coma. Patient No. 71 was received in
coma with the usual low plasma bicarbonate of 22.1 per cent. On
the subsequent days he remained intoxicated and delirious, even
when the plasma bicarbonate was forced as high as 50.2 per cent,
which is near the normal level for a boy of 9 years. Thereafter it
was never below 38.8 per cent, and on the day of death in coma was
48.5 per cent. Patients not in this series have also been seen, who
died in coma notwithstanding normal CO2 capacity of the plasma.
These facts cast no reflection upon the accuracy of the analytical
method, but merely illustrate that dearth of alkali is not the sole nor
essential feature of the condition. Fasting is sometimes beneficial
even when the blood alkalinity falls somewhat; but in particular, a
high alkalinity is no a:ssurance of safety in the presence of obvious
chnical intoxication or a high and increasing concentration of acetone
bodies in the blood.

(h) Alkali Therapy. — This subject is partly discussed in connection
with the results of the treatment of coma, in Chapter VII. The pos-
sible benefits consist in relieving a dangerous dearth of alkali, and in
facilitating the elimination of acetone bodies. The possible harm lies
chiefly in the nausea which may result from oral administration and
the sudden death which may follow within a few hours after excessive
intravenous doses. It is conceivable that alkali may affect the toxic
state for either good or ill in ways not now understood. Both bene-
ficial and injurious effects are illustrated in the present series of
cases.

Close observation also shows that, whether the differences are sig-
nificant or accidental, the condition called diabetic coma does not
present a uniform picture. Aside from the rather atypical fasting
form, there are differences in the symptoms which usher in coma. At
one extreme are patients with extreme dyspnea, gasping so that
speaking and swallowing are difficult, yet with consciousness perfectly
clear until near the end. Such air-hunger is accounted for largely
though not entirely by acid intoxication, and alkali may perhaps save
life. Of patients of this tj^e, No. 63 was saved by alkali even after
he had gone on into unconsciousness, when he might not have been

no CHAPTER n

saved by simple fastingj^ the dyspnea of No. 39 was somewhat re-
lieved by alkali, but nevertheless she went on into stupor and died.
At the other extreme are cases characterized chiefly by malaise,
drunkenness, and drowsiness, with hyperpnea little marked; and these
prodromal symptoms may also be relieved by alkali, sometimes with
surprising promptness. The great majority of cases represent a
mixture falling between these two extremes."

The older clinical literature seems to prove that many patients with
continuous ketonuria were saved from both dyspnea and intoxication
for considerable periods by alkaU, and the onset of coma thus de-
layed. In the treatment of actual coma, alkaH has been seldom
successful, and the patients saved by it are few. Under all circum-
stances, its effect is necessarily temporary and palliative. The fact
is well known that the death rate from coma was not appreciably
altered by the introduction of the alkali treatment. If death was
somewhat deferred, the patient died subsequently in coma neverthe-
less. Magnus-Levy recognized that this result could be prevented
only by some method which would check the process of acetone body
production. Fasting checks this process; accordingly the great ma-
jority of cases of acidosis can be treated by this means alone, and
alkali holds no more than a minor adjuvant position. Its use has
seemed valuable under two conditions. The first is in combating a
long and stubborn acidosis, as in patient No. 23, both for relieving
malaise due to acidosis and for avoiding more serious danger. Ex-
perience does not prove whether it is best given in smaller doses, 5
or 10 gm. daily, for longer periods, or in larger doses on occasional
days when demanded by clinical or laboratory indications. Such a
need is rather rare, and the indiscriminate or routine use of alkali
is not to be recommended. Particularly prolonged administration,
of 2 weeks or more continuously, is probably best avoided, for fear of
harm in some patients. The second use of alkali has been for com-
bating coma in certain cases as already mentioned. Under all cir-
cumstances, it must be understood that control of the metabolic
condition by fasting or food is the essential means of treatment;

"^^This was written before reading the closely similar observations of Cam-
midge, Am. Med., 1916, xxii, 363-373, who suggests that one form is due to loss
of blood alkaU, the other to loss of tissue alkali.

GENERAL PLAN OF TREATMENT

HI

failure in this attempt must end fatally in spite of any dosage of
alkali, and the crisis is not past until the production of acetone bodies
is markedly and progressively diminishing.

In any of the three types of acidosis above described, continuously
high or increasing ketonemia and intoxication lead sooner or later
to a condition where the further administration of alkali is ineffec-
tual. The reason for the failure is unknown, because the real nature
of the intoxication is unknown. The possible irregularities in the
ketonemia and the alkaline reserve are indicated by observations of
Fitz'^ upon three fatal cases of coma (Table II).

TABLE II.

1st observation

, in early coma.

Interval
between 1st

and 2nd
observations.

Sodium
bicarbonate
by mouth
in interval.

2nd observation shortly before
death in coma.

Case No.

CO2 capacity
of plasma.

Total acetone

bodies of plasma

(as acetone)

per 100 cc.

CO2 capacity
of plasma.

Total acetone

bodies of plasma

(as acetone)

per 100 cc.

72 ■

71

sol. per cent
18.9
14.0
22.1

mg.

71.2 .

54.5
83.8

35 hrs.
8 "
8 days

gm.

0

25

72

per cent
26.7
17.0

48.5

mg.
127

97.8
192.5

By reference to the history of case No. 71, it will further be seen
that during 4 days before the final observation, the CO2 capacity
of the plasma ranged from 38.8 to 50.2 per cent, and the total acetone
of the plasma between 212.5 and 368.4 mg. per 100 cc. Also, there
was no constant relation between plasma alkali and plasma acetone.
These cases afford additional illustrations of increasing intoxication
and death notwithstanding rising alkaline reserve of the plasma.
Still other examples might be gathered from the literature to show
that the intoxication is by no means in proportion to the concentration
of total acetone in the plasma. Hence the failure of alkaU is not
necessarily an insufficiency of diuresis resulting in retention of these
acids or their salts. There is no evidence that alkali either increased
or diminished the production or accumulation of acetone bodies at
this stage. This point deserves further investigation. The sugges-

'^ Fitz, R.. Acetone Bodies in the Blood in Diabetes, Tr. Assn. Am. Phys., 1917,
xxxii, 155-158.

112 CHAPTER n

tion, especially of recent English authors," that the explanation hes
in different relative proportions of acetoacetic and hydroxybutyric
acids, the one being more toxic than the other, lacks proof at present.
There is need of more clinical observations and animal experiments
also on this question. In fact, nothing more than a descriptive status
is really estabhshed even for the word "intoxication." Diabetic coma
is a profound breakdown of metabolism. It may well be, in accord
with Woodyatt's ideas, that the abnormality extends through the
whole chain of intermediary compounds, that no one substance will
be demonstrable in lethal quantity and toxicity, but that the general
disorder of protoplasmic chemistry may be responsible for death.
Alkali could necessarily have little influence here. Certainly the con-
dition is complex. Ketonuria, ketonemia, lowered plasma alkalinity,
and clinical symptoms are ordinarily associated in a relation regarded
as t)^ical. The abnormahties of kidney function with severe acidosis
are notorious; they presumably involve variable excretion of acids and
bases; they necessarily upset any calculations based on normal renal
activity; and they may explain more or less of the exceptional behavior
noted. Aside from the occasional spontaneous variations, it is ob-
viously possible to distort the usual relations by artificial alteration of
one feature, for example raising the blood alkali by administration of
alkali, without altering the underlying process or the clinical result.
For practical purposes, sodium bicarbonate is the alkali of choice,
on the basis of effectiveness and innocuousness. A salt of strongly
alkahne reaction, such as sodium carbonate, deranges the stomach
more readily, and its intravenous use involves greater danger of
thrombosis in veins'^ or, in case of leakage, necrosis about them.
Stronger alkalies must be changed immediately into sodium bicarbon-
ate in the circulation, by chemical laws and because an actually alka-
line reaction of the blood would be incompatible with Kfe. This fact
does not necessarily conflict with Murlin's" observation of a differ-
ence in the action of sodiimi carbonate and bicarbonate upon experi-

1* Cf. Hurtley, W. H., Quart. J. Med., 1916, ix, 301-408. Kennaway, E. L.
Biochem. J., 1914, viii, 355-365.

" Cf. Umber, Deutsch. med. Woch., 1912, xxxviii, 1403.

" Murlin, J. R., and Sweet, J. E., /. Biol. Chem., 1916-17, xxviii, 261-288.
Murlin, J. R., and Graver, L. F., Ibid., 289-314.

GENERAL PLAN OF TREATMENT 113

mental animals; but no superiority of strong alkalies in the practical
treatment of human cases has been established. Any special advan-
tages in the use of other bases (potassium, calcium, magnesium) have
also not as yet been demonstrated.

Sodium bicarbonate can be given by the four usual routes.

By Mouth. — This method is preferred when possible. The maxi-
mar dosage is generally 2 or 3 gm. an hour or 5 gm. every 2 hours.
Few patients can take 100 gm. per day, and none can take this for
many days in succession. If the taste is objectionable, it is prob-
ably best disguised by administering in carbonated water. The
most serious objection to the oral method is the possible nausea,
and the dosage should be regulated to avoid this. Diarrhea is also
frequent. More or less edema, generally harmless, may result from large
doses. Defective or sensitive kidneys may possibly suffer injury, and
inhibition of diuresis is a possible serious consequence. On the whole,
this method is the safest and with prudence seldom results in harm.

By Rectum. — The well known drop method is the best. In deep
coma, retention and absorption are generally poor. In a less extreme
stage, this method may be the safest and most convenient substitute
or supplement for oral administration. A mixture of equal parts of
physiological saline and 4 per cent sodium bicarbonate solution (mak-
ing a 2 per cent bicarbonate) was recently given thus to a boy of 12
years for 4 days continuously, and as much as 35 gm. sodium bicar-
bonate and corresponding quantities of fluid were thus introduced
without the least difficulty or irritation. There is a possible question
whether, if the large bowel is filled with injection fluid, there may be
any effect on peristalsis higher up which will aggravate vomiting or
interfere with dosage by stomach. Otherwise there is probably no
objection to giving alkali by rectum.

Intravenously. -^Th.e usual fluid for injection is 4 per cent sodium bi-
carbonate in water or salt solution. Followers of Martin Fischer favor
hypertonic solutions, for withdrawing water from the tissues and for
promoting diuresis. Intravenous alkali injections, instead of being
among the first measures employed, should be resorted to only
reluctantly and on urgent necessity. The possible danger of the
familiar practice of injecting a liter of 4 per cent bicarbonate solution
has already been mentioned. The occasional sudden reviving effect

114 CHAPTER n

is probably due to a circulatory influence of the bicarbonate or the
fluid or both. It is ahnost always temporary, and perhaps carries
in itself the danger of later collapse. There are times when not
enough alkali can be given by stomach or rectum to prevent a danger-
ous fall in blood alkalinity. The intravenous method is then com-
monly used, but the quantities are probably most safely limited to
about 250 cc. for adults, repeated at intervals of several hours if neces-
sary. Presimiably the Woodyatt apparatus for continuous imiform
injection would be best of all. Intravenous alkali injections should be
used to keep the blood alkaU from falling too dangerously low, rather
than to try to maintain it at a normal level, but sometimes remark-
ably large quantities are required even for the former purpose. The
largest doses may be demanded especially in the severest intoxication,
which is the very time when, owing to feeble circulation, the danger
is greatest.

Since boiling changes bicarbonate into the carbonate, solutions
may be prepared in one of the following three ways: (1) by boiling the
solution, and then passing sterile CO2 gas through it to change car-
bonate back to bicarbonate, until a pink color is no longer obtained
in samples tested with phenoIphthalein;i' (2) by making the solution
without boiling, sterilizing it by filtration through porcelain; (3) by
taking clean sodium bicarbonate, preferably from a freshly opened
package of a chemically pure brand, with sterile apparatus into sterile
water or salt solution, without further sterilization." This last and
easiest method is safe enough for intravenous and perhaps even for
subcutaneous use. Solid particles are removed by filtration through
sterile cotton or filter paper if necessary. Solutions are wanned to
body temperature before injection.

Subcutaneously. — Magnus-Levy" called attention to the fact that
sodium bicarbonate, as a neutral salt without marked irritating prop-
erties, can be given subcutaneously. The method is relatively little
employed, because of the fear of infecting or damaging the susceptible
tissues of a diabetic, as well as producing pain or discomfort. One
feature of usefulness was demonstrated in the twelve year old boy

" Magnus-Levy, A., Ueber subkutane Infusionen von Mononatriumkarbonat,
Therap. Monatsh., 1913, xxvii, 838-843. Also Joslin's text, 1917, 397.

GENERAL PLAN OF TREATMENT 115

above mentioned. On his last day of life, 35 gm. sodium bicarbonate
given by rectum were only partly absorbed. 40 gm. given intraven-
ously failed to check the fall of the alkaUne reserve. The patient
was sinking into unconsciousness, with Kussmaul breathing and the
full picture of typical diabetic coma; CO2 capacity of plasma 26.5
volume per cent. A total of 90 gm. sodium bicarbonate in 4 per
cent solution was given subcutaneously between 7 :30 p.m. and mid-
night. The hyperpnea was considerably diminished; there was no
perceptible influence upon consciousness or the general condition for
either good or ill. The slow increase of intoxication continued as
before. Death occurred at 1:40 a.m., and blood taken immediately
after showed a plasma bicarbonate reading of 68.1 volume per cent.
A few authors heretofore have opposed the acid intoxication hy-
pothesis by reporting death in coma with alkaline urine. Inability
to give enough alkali has been a prevalent excuse for failure. There
is no objection to placing enough bicarbonate beneath the skin to
give the patient the benefit of any desired level of alkalinity; and
with the aid of the recent improved methods of estimating the alka-
line reserve, it is possible for any follower of the acid intoxication doc-
trine to convince himself that the patient's blood alkali can be kept
at a fully normal level, but he dies in deep coma nevertheless.

B. Infectious and Surgical Complications and Emergencies.

The methods employed in managing cases of this group are shown
in the individual histories, and the collective results are presented
in Chapter VII. The experience, though favorable on the whole, is
so limited that discussion of the treatment must be based largely on
the literature and on general principles. For the older literature,
reference may be made to text-books and the papers of Umber,i'
Kaposi,!' Kraus,^" and Karewski;^! and for developments under the
newer dietetic methods, to JosUn's text and Strouse's^^ paper. Com-

^* Umber, Deutsch. med. Woch., 1912, xxxviii, 1401-1403, 1433-1434.
" Kaposi, H., Ergebn. Chir., 1913, vi, 52-75 (128 references to literature).
^^ Kraus, F., Deutsch. med. Woch., 1914, xl, 3-8 (with statements by Naunyn,
von Noorden, and Minkowski).
^iKarewski, F., Deutsch. med. Woch., 1914, xl, 8-13.
22 Strouse, S., Med. Clin. Chicago, 1916, ii, 37-52.

116 CHAPTER n

plete discussion of surgical complications, like complete treatment of a
patient, demands the collaboration of physician and surgeon. The
present brief suggestions will omit statistics, most surgical details
and finer classifications, and will be limited to general outHnes of
practical procedure.

Certain broad dicta may be taken directly from former authors.
First, every patient coming for treatment of any medical or surgical
ailment should have the urine tested for sugar, whether diabetes is
suspected or not. There is ample proof that this admonition is far
from superfluous even today. Even with a negative test, Kaposi
urges strict inquiry for diabetes in the family or past history, and
attention to present or past obesity, suppurations, or other sus-
picious indications. Second, mildness of the diabetes and slightness
of the complication or operation promise the best outcome and the
least contraindication to surgical measures; but mild diabetes may
turn suddenly severe with a complication or shock, and a complica-
tion may be aggravated by diabetes, so that unnecessary interference
should be avoided in the presence of any active symptoms, and the
prognosis should always be guarded. The more threatening the
comphcation and the more critical the necessity of surgical inter-
vention, the less is diabetes regarded as a contraindication. Third,
the special dangers threatening the diabetic are peculiar susceptibility
to infection, subnormal healing and repairing power, and acidosis.
The last causes most deaths. The first two are largely overcome by
aseptic and operative care. Fourth, the better the dietetic prepara-
tion, the less the danger. Since acidosis is the chief peril, the best
preparation will include a maximum assimilation of carbohydrate;
therefore formerly ap oatmeal period was recommended (von Noor-
den, Addis, and others).^' Fifth, the surgical technique of an emer-
gency operation should be the simplest yet most effective possible,
avoiding shock, traumatism or long anemia of the parts, elaborate-
ness, and anything tending to lengthen the time of operation or
dispose to subsequent sloughing or infection. Sixth, local or spinal
anesthesia is considered safest from the standpoint of acidosis.
Proper general anesthesia is usually well borne by well prepared

23 Addis, T., J. Am. Med. Assn., 1915, Ixiv, 1130-1134.

GENERAL PLAN OF TREATMENT 117

patients. It should be as brief as possible. Psychic as well as
physical distress should be guarded against. The anesthetic of
choice is nitrous oxide and oxygen. Ether is more dangerous.
Chloroform should never be used for diabetics. Seventh, postopera-
tive care includes on the one hand the most skilled dieting, aiming
particularly at carbohydrate assimilation, and on the other hand sur-
gical precautions, such as exercise and other measures favoring cir-
culation and general hygiene, and avoidance of tight dressings.
Eighth, fatal coma or other disaster may occur from any sort of
operation, in any grade of diabetes, after any form of preparation,
any kind of anesthetic, and any postoperative care (Naunyn, Karew-
ski, and others). Ninth, operative relief from tumors or other
troubles sometimes has a beneficial influence upon the diabetes
(Eising and others).^ Tenth, the use of alkali stands on about the
same basis as in uncomplicated cases. The frequent occurrence of
acidosis with operation or anesthesia in non-diabetics has been brought
into some prominence of late (Crile,^^ Bradner and Reimann,*^ Bum-
ham,*' Lincoln,^' Morriss,*' and others). The recent work of Hen-
derson and Haggard^" indicates that the lowering of the carbon
dioxide capacity of the plasma does not represent a true acidosis.
Accordingly, only the acetone body production can here be regarded
as evidence of acidosis. The treatment has consisted in preliminary
carbohydrate diet, and, in emergency, glucose and sodium bicarbon-
ate, alone or separately, orally, rectally, subcutaneously, or intra-
venously. The glucose is unquestionably the more important for a
non-diabetic. The value of alkali has been questioned. Naunyn
strongly advocated saturating every diabetic with sodium bicarbon-
ate before operation, and he has had the largest following. Undoubt-
edly the blood alkahnity can be raised by alkali dosage, but there is
the open question whether artificially raising the blood alkalinity is

2* Eising, E. H., /. Am. Med. Assn., 1914, Ixii, 1244-1245.
" Crile, G. W., Ann. Surg., 1915, Ixii, 257-»-263; ^w. Med., 1916, xxii, 447^51.
2^ Bradner, M. R., and Reimann, S. P., Am. J. Med. Sc, 1915, cl, 727-733.
"Burnham, A. C, Am. Med., 1916, xxii, 438-441.

28 Lincoln, W. A., Ann. Surg., 1917, Ixv, 135-141.

29 Morriss, W. H., /. Am. Med. Assn., 1917, Ixviii, 1391-1394.

5" Henderson, Y., and Haggard, H. W., J. Biol. Chem., 1918, xxxiii, 333-371.

118 CHAPTER II

necessarily synon37inous with benefiting the patient. Alkali has not
prevented the high mortahty from postoperative acidosis in the past,
Strouse has had good results in operations with alkali, and Joslin
in operations without alkaU. The practitioner's choice in individual
cases will be governed by his attitude on the general subject.

Contrary to past practice, alcohol is at present not used in this
hospital as a food at any stage in diabetic complications or the
acidosis accompanying them.

Authors have divided complications into those for which the diabetes
is wholly or partly responsible, and those independent of the diabetes.
Therapeutic measures are sometimes influenced by theories as to the
reason why diabetics are subject to so many characteristic compli-
cations and so lacking in resistance to damage of all kinds. Notions
that excess of sugar directly injures tissues or provides a favorable
medium for bacteria have been sufficiently discredited. It is also
important to emphasize that thougli malnutrition predisposes to in-
fection, the susceptibility of diabetics is something special and
peculiar, since hunian beings or animals suffering from other condi-
tions involving equal or greater inanition and cachexia are not
afflicted in this manner or degree. As formerly pointed out," one
general conception of diabetes is apphcable also to all complications.
The present treatment is built upon the idea, supported by consid-
erable evidence in addition to the treatment, that diabetes is weak-
ness of the general nutritive function, including both cataboUsm and
anaboHsm. It is thoroughly in line with this poin^ of view that every
part of the diabetic body should manifest diminished power of main-
taining normal function, of repairing the natural wear and tear, of
healing wounds, and of resisting infectious invasions. Not only the
grosser complications, but also retinitis, cataract, arteriosclerosis,
neuritis, asthenia out of proportion to loss of flesh, and the multitude
of other disorders listed in classical text-books, accord with this con-
ception. Since the trouble is due to deficiency not of nutritive ma-
terials but of the nutritive function, relief should be expected from
strengthening this function, even at the price of dimmished food supply
and body weight. Experience indicates that this result actually

«i Men, Am. J. Med. Sc, 1917, cliii, 313-371.

GENERAL PLAN OF TREATMENT 119

follows, and that there should be no hesitation to impose rational un-
dernutrition for the purpose of raising resistance.

Complications and operations fall for practical management into
those with which there is opportunity for preparation, and those
affording no opportunity for preparation.

1. When There is Time for Preparation.

(a) Prophylaxis. — ^Just as the food tolerance is never fully restored
in typical diabetes, so also the Resistance is probably never entirely
normal. It is possible, for example, that no dietetic treatment will
ever bring the resistance to tuberculosis quite to normal, and that the
incidence of this disease will accordingly always be higher among
diabetics than among the general population. Also, if an infection
does gain lodgment, there is always the danger that diabetes will be
made worse and that resistance will collapse correspondingly. On
the other hand, resistance is probably highest when a diabetic is
kept as nearly as possible like a correspondingly undernourished
non-diabetic. Reduction of diet to something like the Chittenden
standard has never been shown to cause serious lowering of resist-
ance. Below this scale, freedom from symptoms necessitates emacia-
tion and weakness in proportion to the severity of the diabetes; but
it has repeatedly been pointed out that feeding beyond the tolerance
gives only a temporary and dearly bought benefit to weight and
strength, and it seems evident that such an attempt actually lowers
resistance at all stages. Three points of prophylactic advantage from
efficient dietetic treatment can be set down as facts. First, the long
list of complications which have been the chief torment of diabetic
patients in the past are largely prevented; a pimple does not de-
velop into a carbuncle; an abraded toe heals instead of becoming
gangrenous, etc. Second, the aggravating influence of complications
upon, diabetes is thus either avoided or reduced to a minimum.
Certain cases in the present series show the occasional possibility of
attaining the ideal that a patient shall pass through a crisis of in-
fection or operation without developing either glycosuria or acidosis;
and in a larger proportion it is possible to avert acute death and also
guard against any lasting injury to the diabetes. Third, health and

120 CHAPTER II

resistance are maintained either indefinitely or for the longest pos-
sible time, whereas overfeeding entails progressive decline in all re-
spects and corresponding liability to and damage from complications.

(&) Preparation for Emergency. — This is generally synonymous with
preparation for operation. The time available naturally varies with
the surgical condition, but something like a tumor or a quiescent
appendix may permit all necessary leisure and care. Active diabetes
is first controlled in the usual manner. A carbohydrate period is
important thereafter; and if acetone is persistent, it is probably best
to continue the highest possible carbohydrate diet without fat until
the Rothera reaction is negative if possible. The blood sugar and
all other tests should also be brought to normal if circumstances per-
mit. Meantime, protein will lower carbohydrate assimilation and
may tend to prolong acidosis, but will support strength better than
any other food. It may be called an ideal preparation which sends
a patient to operation after a fat-free diet of 1.5 gm. protein per
kilogram of weight and the highest feasible carbohydrate ration, with
all laboratory tests normal. In case of sudden damage of assimila-
tion from operation or anesthesia, this arrangement insures the
greatest possible liability to glycosuria, which is generally easy to
control, and the least possible liability to acidosis, which is the chief
danger. Joslin and Strouse give examples of preparation along these
lines. The latter, for example, prepared a woman with a fat-poor
diet of eggs and 85 gm. carbohydrate, so that the urine was free from
sugar for 15 days and from acetone for 5 days before operation. A
combined hysterectomy, right salpingectomy, and oophorectomy,
under nitrous oxide preceded by morphine and atropine, was then borne
without incident other than one day of glycosuria. While diabetes
necessarily involves operative danger, it is believed that these prin-
ciples offer the best chance of safety.

(c) Treatment with Subacute or Chronic Complications. — ^As men-
tioned elsewhere, some complications, such as nephritis, require no
departure from ordinary management. Others, such as infections
or pregnancy, have interrelations with diabetes which are important
in influencing both conditions. On the whole, the most serious
medical complication is tuberculosis, and especially the conflict is
sharp here between the overfeeding customary for one disease and the

GENERAL PLAN OF TREATMENT 121

underfeeding demanded by the other. Severe tuberculosis with
severe diabetes makes an inevitably fatal prognosis. When either
disease is mild, the chance is a little better but by no means good.
When both are mild, treatment is more hopeful. A number of
patients imder observation by recognized tuberculosis specialists
have improved strikingly when taken off the traditional high diet
and placed on a lower diet which abolished their diabetic symptoms.
It is believed that this plan, with the usual fresh air and other
measures, promises the best results with this combination.

This belief is corroborated by the experience with surgical compli-
cations, which proves plainly that tissue vitality and resistance to in-
fection are built up by treatment which controls the diabetes. The
most numerous class of surgical troubles are furunculosis and gan-
grene. The best local treatment of both is palliative and conserva-
tive. Surgical authorities seem to agree that incision of boils should
be avoided, unless absolutely demanded by spreading infection or
toxic absorption. Gangrene has been the occasion for multitudes
of needless operations and deaths in the past. Together with cata-
ract, retinitis, neuritis, and less numerous ills, it furnishes the strong-
est reason for treating diabetes in the elderly as carefully as in the
young; for notwithstanding the part attributed to arteriosclerosis or
other causes, efficient dietetic treatment prevents such troubles almost
without exception. Stetten and Lambert and Foster,'^ and others have
proved the advisability of treating gangrene conservatively when pos-
sible, with diet, measures to improve circulation, and simple local
care. Even tissues appearing dead may revive to surprising degree.
-A line of demarcation becomes established, and operation is either
avoided or reduced to a minimum. It is bad advice to operate early
and high, where the tissues and vessels are sound; and patients should
not be operated on without dietetic preparation. The only indications
for abandoning expectant treatment and operating promptly are ad-
vancing infection or fever and intoxication, not checked by other
measures and threatening danger either in themselves or in their
influence upon the diabetes. Here the treatment demanded is that

=2 Stetten, D. W., /. Am. Med. Assn., 1913, Ix, 1126-1133. Lambert, A. V.
S., and Foster, N. B., Ann. Surg., 1914, lix, 176-185.

122 CHAPTER n

for an emergency, as discussed below. Otherwise, even if operation is
later necessary, the longest possible time is afforded for preparation.
Death from amputation should then nearly always be avoidable.
The worst result recorded after such preparation is that of Baldwin,^'
whose patient's urine quickly became free from sugar and acetone,
and amputation under ether 3 weeks later was followed by death in
coma within 2 days. Owing to lack of details, it is not possible to
judge the fitness of the preparatory diet. Though such cases are
generally rather mild, yet there is always the possibility of genuinely
severe diabetes in an old person, or of continuous injury of assimila-
tion by a chronic infection, so that either early or late operation
may end in disaster. Complete laboratory tests are generally a reli-
able means of judging whether operation is safe or not.

2. When There Is Little or No Time for Preparation.

The most dangerous emergencies are the cases suddenly presenting
themselves with serious infection coupled with intense diabetic symp-
toms. Some of the examples of exaggerated nitrogen loss, maximal
D : N ratios, and uncontrollable acidosis belong in this class; e.g.,
Joslin's^* case No. 513. As the diabetes makes the infection worse
and the infection makes the diabetes worse, it is frequently impossible
to break the vicious circle, and a large proportion of such patients die.
There probably is no constant rule of diet except to exclude fat. On
the one hand, these patients are specially subject to fasting acidosis,
so that feeding with carbohydrate or protein, either or both, may be
necessary, perhaps for a majority. On the other hand, if past experi-
ence indicates correctly that ordinary coma responds better to fast-
ing than to carbohydrate, there is a chance that the same may be
true of some cases with infection, and that control of the diabetes by
the quickest and most radical means possible may be the one hope of
saving life.

As with uncomplicated cases, the plan in this hospital with infec-
tions has been to impose immediate fasting and then depend upon
clinical and laboratory indications for guidance. Chapter VII and the

'« Baldwin, J. F., Am. J. Surg., 1916, xxx, 65.

^* Joslin, E. P., Treatment of Diabetes Mellitus, 2nd edition, 1917, p. 353 fi.

GENERAL PLAN OF TREATMENT 123

case histories show the collective and individual experiences and re-
sults. Medical emergencies, even of such magnitude as lobar pneu-
monia, have for the most part been met successfully. Fasting has
benefited some patients, while others have done well on low carbo-
hydrate-protein diets. It is believed that the results on either plan
are more favorable than are possible under any method based on the
fallacy of overfeeding for the sake of strength.

Surgical complications offer one more element of hope if the sur-
gical treatment can succeed. The decision between radical and
conservative measures is often most difl&cult and doubtful. On the
one hand, dietetic control may revolutionize the surgical state and
the infection may come quickly to a standstill, when operation might
be fatal. Thus the life of the carbuncle patient No. 27 was probably
saved by immediate fasting. On the other hand, with mistaken
delay either the diabetes or the surgical condition may quickly be-
come hopeless, and what is demanded is the most prompt and radical
surgical intervention. Strouse gives an example of success due to
right judgment. A pregnant diabetic woman with threatening
acidosis was placed first on a low vegetable diet, but progressed rap-
idly toward coma. Accordingly Caesarean section was performed
under morphine and local anesthesia. Acidosis remained high for 2
days, then cleared rapidly, and the patient was soon out of danger.
The results of radically terminating a complication are apt to be
most brilliant when, as in this case, the diabetes is inherently mild
and is only stirred to intensity by the complication or by wrong diet.
Both complications and operations are extremely dangerous in severe
cases with flagrant symptoms. As the Carrel-Dakin method has
been so widely adopted by surgeons, it is only necessary to mention
the great importance of effective wound sterilization, not only for
saving gangrenous limbs, but also in carbuncles or other surgical in-
fections, to put an end to toxic absorption with the least possible
shock or delay. With advancing sepsis, a quick amputation of a
limb or removal of an appendix or other focus, even in the presence
of threatening acidosis, may save life in a minority of cases.

Postoperative care is adjusted to meet conditions. A well prepared
patient, coming through operation symptom-free, may have his diet
built up as in absence of comphcations, first with carbohydrate, then

124 CHAPTER n

with protein, finally with fat. In the presence of an emergency, the
usual choice must be made between fasting and feeding for acidosis,
following careful clinical and laboratory observations rather than any
fixed rule. Nutrition and reparative power, emphasized by Jopson,'*
are doubtless best served by protein as usual. While acidosis is the
chief danger, absence of glycosuria should be maintained or achieved
as early as possible, even at the price of lowered nutrition.

All cases of this entire group demand the constant combined watch-
fulness of the best surgeon and the best diabetic specialist available.
With this cooperation Joslin's statistics show the favorable results
obtainable in some of the most desperate cases.

5" Jopson, J. H., Tr. College Phys. Philadelphia, 1916, xxxviii, 255-257.

IV. Treatment Following Cessation of Glycosuria.

Here are to be considered (A) the carbohydrate tolerance test;
(B) the maintenance diet; (C) the period of observation and instruc-
tion; and (D) the period of after-care.

A. Carbohydrate Tolerance Test.

After a patient becomes free from glycosuria, his fast is continued at
least one day longer, so as to assure at least 24 hours of complete
sugar-freedom before giving food. This plan also is based upon the
idea of resting the weakened function. In mild cases, it is permissible
to start the test when the patient is sugar-free, even without fasting.
In severe cases with h3^erglycemia a fast-day usually precedes a
carbohydrate test, even though glycosuria is already absent. In the
severest cases of all, when the patient is extremely weak and the tol-
erance is known to be trivial, the carbohydrate period is sometimes
omitted and a period of gradually increasing protein substituted. It
may be rather important to judge the severity correctly in this re-
spect. Appearances may deceive the inexperienced, so that the
benefits of the carbohydrate period are unnecessarily sacrificed in a
patient actually possessing considerable reserve strength and toler-
ance. On the other hand, with genuinely extreme weakness there is
the possibihty of a fatal collapse of strength on the low vegetable
ration, which would be prevented by protein. This danger is really
serious only in children, because the collapse may come suddenly.
Adults weaken so gradually that there is plenty of opportunity to
avert collapse by substituting a low calory protein diet.

The standard program of the carbohydrate test has been to give
10 gm. carbohydrate the first day, and increase by 10 gm. daily until
the limit is reached. The first trace of glycosuria does not neces-
sarily represent the limit. When the first glycosuria appears, the
practice has been to repeat on the following day the same quantity
of carbohydrate which caused glycosuria. If the glycosuria disap-

125

126 CHAPTER n

pears, the regular increase of 10 gm. daily then continues, and occa-
sionally the true tolerance is found to be several times the quantity
on which the first accidental trace of glycosuria appeared. When
glycosuria occurs on two successive days with a certain intake, the
tolerance is considered to be 10 gm. less than this; i.e., the highest
quantity taken without glycosuria is regarded as the tolerance.

The test is ordinarily carried out with green vegetables, for pur-
poses of uniformity, and because they are the most bulky and there-
fore most appreciated form of carbohydrate. The benefit of salts,
vitamines, etc., in vegetables is a possible accessory advantage. On
the first days, the hungry patient is naturally best pleased with the
vegetables lowest in carbohydrate, which afford the greatest bulk.
If the tolerance is high, the bulk soon becomes excessive. As far as
possible, the patient's wishes are allowed to determine the choice of
vegetables. While the approxinaate grouping into classes of 5 per cent,
10 per cent, 15 per cent, etc., is a convenient guide in selection, it is
necessary especially in severe cases to reckon the carbohydrate of
each vegetable as accurately as possible from the standard tables, if
the test is to be at all exact. With a high tolerance, the lower class
vegetables are gradually replaced by those of higher carbohydrate
content, until finally, with the highest tolerance, bread and cereals
may be reached, though preference is given to potatoes and garden
vegetables as long as possible, in order that absorbable protein may
interfere as little as possible with the pure carbohydrate tolerance.
Fruits are also permitted during the carbohydrate test, beginning
generally with grapefruit in the earlier stages and advancing to those
richer in carbohydrate. The fruit never represents more than a
rather low fraction of the total carbohydrate intake, and with this
arrangement the fruit sugar has seemed to make no important dif-
ference as compared with starch in fixing the tolerance.

Modifications of the standard plan are used chiefly to suit var3dng
degrees of severity. It will be observed that the scheme outlined is
particularly adapted to severe cases with low tolerance. If the tol-
erance were 300 gm., an increase of 10 gm. per day would require a
month for carrying out the test. The feasibility of prolonged vege-
table diets is illustrated by cases Nos. 1 and 3, but they have no
special virtue beyond the low calories, and exaggerated length of a car-

GENERAL PLAN OF TREATMENT 127

bohydrate test is generally undesirable. For this reason the increase
in the milder cases is more than 10 gm. per day, sometimes as high
as SO gm. per day. Two points are to be borne in mind in regard to
such modifications. First, the tolerance determined by a rapid test
is by no means strictly comparable to that found in a slow test in the
same or another patient, inasmuch as the slower increase, by more
prolonged undernutrition, builds up a definitely higher assimilation.
Second, too short a test sacrifices much of the benefit, and a week or
two if possible is profitably spent as a carbohydrate period.

The purposes served by the test are diagnostic and therapeutic.
Therefore it is repeated at 6 months or other intervals, as may seem
convenient or desirable.

Diagnostic. — ^First, the carbohydrate test serves as a basis for
reckoning the subsequent carbohydrate allowance. The assimila-
tion is considerably higher for carbohydrate taken alone than in a
mixed diet, but the test gives a standard basis of reckoning. Second,
the use of a uniform test permits comparisons between patients and
between the same patient at different times, for judging both the
severity of the case and the progress under treatment.

Therapeutic. — ^First, most patients at the end of their fast have
more or less acidosis. The vegetable period, which enables the
highest possible assimilation of carbohydrate, is for this reason the
quickest and most effective means of relieving acidosis. Ketonuria
diminishes, and the. plasma bicarbonate rises without alkali dosage.
Individual peculiarities regarding acidosis may be indicated by the
varying stubbornness with which it resists carbohydrate ingestion.
Second, there is important benefit in the undernutrition, which at
first is almost like fasting.

B. The Maintenance Diet.

When the limit of tolerance has been reached in the carbohydrate
test, a single fast-day is given to clear up glycosuria. Then (or im-
mediately after the initial fast, if for any reason the carbohydrate
period is omitted) the building up of a maintenance diet is begun. A
fuU diet is not begun suddenly, for fear of bringing back symptoms.
As may be seen in the case histories, scarcely any two cases have

128 CHAPTER n

been managed identically; the regime has been individualized to suit
individual needs. With acidosis, carbohydrate is kept as liberal as
possible. For weakness, protein is raised rather rapidly to 1.5 or at
least 1 gm. per kilogram of body weight. Fat is added last, the
addition is made slowly, and the final allowance is kept within the
tolerance as nearly as this can be determined. Under the special
conditions, the fat ration is what essentially determines the body
weight, but the latter has been allowed to fall until a maintenance
diet can be assimilated without obvious diabetic s}anptoms.

A few cases in this series have been of a grade of severity indicated
by the fact that, after cessation, glycosuria would return when the
diet consisted solely of a few hundred grams of thrice cooked vegetables
on certain days or of six or less eggs on other days. With such a
trivial food tolerance, the diet is best limited to the small quantity
of protein which can be taken without glycosuria, until the assimila*
tion improves. For the most part, however, mixed diets have been
given following the carbohydrate test, the increase being preferably
limited to one class of food at a time, so as to observe the respective
effects of the addition of carbohydrate, protein, or fat. The prin-
ciples of the dietary plan were so clearly stated by Taylor'^ that
his remarks are worth quoting at some length.

"It is impossible in a discussion of so large a subject as diabetes to do more
than present briefly a few points. The clinician, even of the most advanced
modern type, who views the work that for the past ten years has been devoted
to the intermediary metabolism of diabetes ought not to obtain the notion that
this matter comprehends the substance of the disease entirely, and that upon the
elucidation of the intermediary metabolism now under investigation depends our
knowledge of the pathogenesis of the disease. Certainly, the laboratory investi-
gator has no such conception. If up to the present the laboratory investigations
have laid special stress upon the intermediary metabolism, it is because it is the
most suitable phase for investigation. Nearly aU the studies deal with abnormali-
ties in the catabolism of fat and sugar because these reactions lend themselves
to investigation. But there is a broader view-point that every laboratory man
must recognize, and which every clinician should understand, which may ex-
plain many of the divergent features of diabetes. The up-building processes of
the body can never be dissociated from the puUing-down processes. There is no
such thing as a disturbance in the burning of sugar without an effect upon the

^' Taylor, A. E., Tr. College Phys. Philadelphia, 1916, xxxviii, 254-255.

GENERAL PLAN OF TREATMENT 129

anabolism of sugar in the tissues, and likewise no disturbance in the burning of
fat without similar influence in the building-up process of fat. Fat and sugar
are vital in the building up of metabolism. We have every reason to believe that
when the body cannot burn sugar and fat it cannot utilize sugar and fat in con-
structive anabolism. Abnormalities in the utilization of sugar and fat in the
building-up processes may be as important in the production of certain symptoms
of diabetes deahng with resistance as are the abnormaUties in the catabolism.

"I would, in the second place, draw attention to one point in connection with
the current use of the Allen treatment, which is based upon a misconception.
When the diabetic has been made sugar- and acid-free, how far shall he continue
his dief ? Shall his increase of food be controlled by the urinary signs or shall he
adopt other criteria? It has not been demonstrated that it is necessary to give
the usually stated 40 calories per kilo. Investigations have recently shown that a
man of 70 kilos may live sixty days upon a diet of coarse bread, potatoes, cheese,
and eggs, containing about 2000 calories, without loss of weight. If such a man
should happen to have diabetes and were subjected to the Allen treatment, it
would be an absurdity to attempt to feed him back to 40 calories per kilo. The
man dealing with a patient should bear in mind that what he needs to feed to
is not the normally high maximum of calories but the low minimum standard of
calories."

As stated in the preliminary publications, in accordance with the
principle underl3dng the entire treatment, the fact that a person is
diabetic calls for restriction of his total diet, and, in proportion to the
severity of the diabetes as indicated by the carbohydrate tolerance,
the allowance of all three classes of foods should be diminished. With
regard, to the necessary influence of such restriction upon body
weight, it was advised that every patient, no matter how mild the
diabetes, be kept a few pounds, preferably at least 10 or 15 pounds
and in obesity more, below his usual former weight. In proportion
as the diabetes is more severe, the weight as well as the diet should
be kept lower. Overtaxing the anabolic side of metabolism by at-
tempts to make patients carry too much weight will, in accord with
Taylor's expression, bring a return of active diabetes manifested chiefly
by excretion of products of deficient catabolism; while lightening the
anabolic burden by reduction of body mass makes its benefit evident
in an unproved catabolic function.

There is a further interrelation between reduction of weight and
diet. It is known from earlier metabolic studies that undernutrition
reduces the food requirement not only absolutely but also relatively;

130 CHAPTER n

i.e., not only are there fewer kilograms of weight, but also fewer ca-
lories are needed per kilogram. A recent illustration is afforded in the
observation of Anderson and Lusk," that a dog after fasting 13 days
showed a diminution of 20 per cent in weight and of 28 per cent in
heat production. A special point in the study by Allen and DuBois
lay in establishing the influence of this principle upon diabetic me-
taboUsm. It was there shown that G. S. (patient No. 10 in the
present series), starting with a basal metabolism 2 per cent above the
average normal when severe diabetic symptoms were present, dropped
to 21 per cent below normal on the eighth day of his fast. This
calculation was based upon the DuBois height-weight formula; and
as the weight was 31 per cent below normal, the reduction below
tie original normal metabolism was far more than 21 per cent. The
reverse change was demonstrated in W. G. (patient No. 8 in the
present series). "Starting at 26 per cent below normal on January
11, when glycosuria was absent, his metabolism rose, on increased
diet and the return of active diabetes, to 20 per cent below normal on
January 15 and to 11 per cent below normal on January 22." This
patient was 42 per cent below his normal weight, so that the absolute
reduction below his original normal energy exchange was far greater.
These experiments carried out by DuBois estabHshed one essen-
tial point in this theory of treatment; viz., that a relatively high me-
tabolism accompanies active symptoms in the severely diabetic pa-
tient, and that the fasting and low diet which control these symptoms
enable him to descend to the low metabolic level proper to him as an
emaciated human being, so that his maintenance requirement falls as
low as that of any other equally emaciated individual.

Lusk"* summarized the case studied by Geyelin and DuBois as
f oUows :

"When the patient was intensely diabetic, the number of calories produced
per hour, as measured by the calorimeter, was 73.2. The weight of the patient
was 56| kilograms. The heat production was normal for that weight. Later,
through the starvation, the weight fell from S6J kilograms to 46 kilograms, and
the man developed a high degree of tolerance for carbohydrate. The calories

»' Anderson, R. J., and Lusk, G., J. Biol. Chem., 1917, xxxii, 421^45.
'^Lusk, G., Tr. College Phys. Philadelphia, 1916, xxxviii, 244-248.

GENERAL PLAN OF TREATMENT 131

produced per hour fell from 76.4 to 43, or was 35 per cent under the normal for
the lower body weight. Thus he requires only about 60 per cent of the food that
he had required previously when he was heavier and diabetic."

Patient No. 54 also was studied in the calorimeter by DuBois. The
findings quoted in her case record show that the metabolism of this
extremely emaciated woman was the lowest ever recorded, and
"only 40 per cent of the original heat production was necessary for
life."

The nitrogen output of this patient was not correspondingly re-
duced; and, though authors from Sivdn to Chittenden have demon-
strated how low the protein metabolism of normal persons may be
brought, it has been constantly borne in mind that protein is the
most essential food and its reduction the most risky of all. It must
be duly regtUated, not only because it is a food and a source of both
sugar and acetone, but also because its specific dynamic action is
greater than that of any other food in increasing metabolism. As the
body weight is low, 1.5 gm. per kilogram have been arbitrarily chosen
as a standard allowance of protein. Freedom from glycosuria is pos-
sible on a higher protein ration with fat restriction than with
unlimited fat. The new method therefore has the advantage over
former ones in this respect, and is sufficiently elastic to allow such
balance of the diet as may suit individual beliefs in favor of high or
low protein.

It is worth mentioning that the calorimetric results quoted have
been obtained with ingestion of little or no carbohydrate. Persons
acquainted with the literature need not be reminded that the in-
crease of nitrogen excretion or of total metabolism on withdrawing
carbohydrate or replacing it with fat applies only to high fat rations
or to a certain standard of metabolism; for by lowering the level of
nutrition it is always possible to reduce both total and protein metab-
olism very low, even without carbohydrate. The slightly greater
sparing power of carbohydrate is, however, one reason for retaining
it in the diet, as noted below.

Patients with the emaciation and minimal diet corresponding to the
severest diabetes are necessarily far below normal in strength. The
above mentioned investigation of Anderson and Lusk is of special
importance with regard to the muscular activity of such patients.

132 CHAPTER II

These authors proved that when a dog was reduced in weight by
fasting, there was a saving of energy when the animal ran in a tread-
mill, because less energy was required to move the lighter body. But
when the calculation was based upon the absolute work performed,
the expenditure of energy was exactly the same before and after
fasting; that is, the organism can economize in its basal metabolism,
but the same absolute labor costs the same absolute energy, irre-
spective of the state of nutrition. In diabetes, however, there are
additional factors, namely the non-utilization of much of the energy
contained in high diets, and the preternatural weakness and lassitude
due to the resulting intoxication. Williams'^ has carried out a unique
investigation by dynamometer tests of patients under treatment,
demonstrating directly an increase of muscular strength when the diet
is reduced so as to bring it within the metabolic capacity.

The following are fair conclusions from the evidence at hand. Per-
sons with mUd diabetes are as a rule easily enabled to maintain them-
selves on mixed diets with moderate restrictions which reduce their
weight but raise their efl&ciency and comfort practically to normal.
Persons with moderate diabetes require more rigid restrictions,
which bring them more or less below normal, but yet their diet is more
agreeable and their comfort and usefulness maintained both higher
and longer than on limitation of carbohydrate alone. Patients with
severe diabetes necessarily face the hardest conditions. The investi-
gations have shown the enormous load of useless and injurious metab-
olism carried by such patients with their active symptoms, and the
striking reduction of this burden under treatment which controls
symptoms. The low metabolism and efficiency of inanition remain.
There may be a tendency to calculate diets which appear absolutely
low, but yet are luxus rations for this state and injure assimilation
accordingly. The sympathy of the inexperienced onlooker is strangely
greater for weakness and emaciation held in check by a tight rein on
diet, than for the worse and rapidly progressive condition which, on
overfeeding, appears as the simple consequence of the disease. It is
possible for any case under unskillful restrictions, and for a few cases
even under the most expert care, to end in actual death from starva-

'8 Williams, J. R., Arch. Int. Med., 1917, xx, 399-408.

GENEILA.L PLAN OF TREATMENT 133

tion; but Joslin's and the present statistics agree in showing that this
is not one-tenth as frequent as other causes of death, notably coma.
Had circumstances permitted, the present series of cases might have
afforded unusual material for a study of undernutrition, and might
also have established the lower limits of a maintenance diet, which at
present are unknown. It can only be said empirically that with re-
markably few exceptions the curve of falling weight and the curve of
rising assimilation meet at a level on which life can be maintained.
The best experience seems to agree that, when such treatment is
properly carried out, the unavoidable hunger and disabiHty are less
distressing to all concerned than the troubles accompanying acidosis
and complications under former methods.

C. The Period of Observation and Instruction.

Treatment can seldom be inaugurated or patients instructed as
satisfactorily elsewhere as in a hospital with a well conducted metab-
olism ward. This statement apphes not only to the critical cases,
where the advantages are most evident, but even to the mildest ones.

For the physician, a hospital offers the best facilities for the two
prime essentials of treatment, accurate diet and laboratory control.
He is also spared much unnecessary labor and inconvenience if the
organization is right.

For the patient, a hospital offers relief from work and worries, and
both theoretical and practical education concerning diabetes. One
test of treament is found in the fact that under proper conditions a
patient is benefited by contact with other patients. Any fears con-
cerning his own initiation are relieved on acquaintance with others
who have gone through the same or more. He sees and hears the
actual consequences of following or breaking diet, and his choice is
generally for fidelity. He falls naturally, into the habits of his en-
vironment, and learns so much from his neighbors and the general
atmosphere of the place that instruction is made very easy.

Much of the benefit of the early stage of treatment is often lost by
undue brevity of the observation period. The extremely long hos-
pital sojourn of most patients in the present series is accounted for
partly by the severity of the cases, and partly by the requirements of

134 CHAPTER II

investigation. Few patients can remain in private institutions so
long, but also comparatively few cases are so severe. It may seem
that little is really being done after the first brief period of most active
treatment, and that a longer stay imposes a cost in time and money
which is unjustifiable, especially for poorer patients. It is unfortu-
nate that poverty and necessity shorten the hospital period in-
juriously in so many cases, and that public institutions are gener-
ally so ill equipped to care properly for diabetics. Also much is ac-
complished by the classes, clinics, and social service work conducted
for diabetics by some of the best institutions and specialists. But, as
a rule, the ideal hospital experience for a mildly diabetic patient can
seldom be less than 2 weeks, and for severe cases the time may extend
into months.

For observation, this period is useful in order to determine the true
food tolerance, so as to plan a diet which is neither too high, thus
causing injury of assimilation and later relapse, nor too low, thus
occasioning unnecessary privation and loss of weight. Laboratory
tests, employed as described hereafter, are the chief means of judging
progress. The patient should not be discharged until these tests give
either normal results or adequate assurance of continued progress in
the right direction.

For instruction, this period is used to equip the patient with a
sufiicient working knowledge of the care of his own case. Experience
has shown that the simple essentials can readily be mastered by even
the least educated persons, if they are willing and conscientious.
Diets are readily calculated by the more intelligent patients, especially
as the plan followed is so simple. Uneducated patients are sent out
with fixed written menus, together with a list of absolute quantities
of other foods which may be substituted for individual dishes on the
standard menu. Before leaving, a patient generally spends most of
his time for about a week in the diet kitchen, participating in
the actual preparation of his own and others' diets. He is thus
of some service, and at the same time acquires practice in cook-
ing and calculation which guards against mistakes at home. .
Men, women, and children alike are generally put through this prac-
tical training; but when a relative, servant, or other individual will be
largely concerned in the actual labor, this person is also given the

GENERAL PLAN OF TREATMENT 135

course of instruction. For testing the urine, the Benedict sugar
method alone is sufficient, and can be learned by anybody. The
tests, in severe cases or if the blood sugar is high, are best carried
out upon the four separate urine specimens of each 24 hours, as done
in the hospital. There is no harm in patients' learning as many lab-
oratory reactions as they like, but the sugar test is really all they
need to know, and they are more liable to become morbid over too
many tests. Under proper conditions, only very rare patients are
made nervous or hypochondriacal by performing their own sugar
tests, so that these must be made for them by other persons. They
must be equipped with definite knowledge of what to do if glycosuria
appears. The best psychic state is generally assured when they
know they are regularly and consistently sugar-free, and have confi-
dence in their ability to control glycosuria if it appears.

D. The Aeter-Care.

The period of after-care properly extends over the remainder of the
patient's life. For a considerable time at least, he should keep an
accurate record of the facts pertaining to his case, most conveniently
on a printed form supplied for the purpose. Such a record should
include the naked weight, the exact diet, the urinary reactions, and
the subjective health. No matter how thorough the instruction in
hospital, questions and difficulties often arise, especially in the early
period after returning home. The patient is encouraged to ask
advice when needed, but particularly is ordered to report regularly at
intervals ranging from one week in severe cases to several months in
mild cases. Some reports may be made by letter, especially by pa-
tients at a distance, but it is necessary for intelUgent supervision"
that the patient present himself in person at definite times. Occa-
sional emergencies also arise, and the patient should have some
knowledge of how to meet them. For example, many may profit
by the advice that in case of any infection, they should immediately
omit fat from the diet. But such an emergency should be reported
without delay to the physician in charge, in order that he may superin-
tend any further measures necessary.

136 CHAPTER II

When a patient reports in person, his naked weight and a urine and
a blood sample are taken. The accuracy of his record is thus checked.
If the blood sugar is normal, and the nitroprusside test is negative in
urine (Rothera) and in blood plasma (Wishart), practically nothing
else is needed. If all is not so favorable, such other analyses are
performed as may be necessary to show whether there is danger or
what is the direction of progress.

These occasional tests are the guide for such adjustments of diet
as may be necessary from time to time. The severely diabetic
patient requires rather close supervision for checking wrong tenden-
cies in their incipiency and for the best results in general. The en-
couragement and moral support gained in personal contact are fur-
thermore specially important in the severe cases, though a high pro-
portion of milder cases without it will sooner or later go wrong. A
case lost from sight is generally a failure. Milder diabetes should not
involve invalidism or irksome dependence; but these persons, even
while leading comfortable and useful lives, should keep in touch with
their medical adviser, for experienced oversight of their condition and
diet and for information concerning advances in treatment.

V. Ideals of Diet and Laboratory Control.

In the earliest preliminary outlines of this treatment, the plan was
defined as an attempt to spare a weakened function by rest, and to
this end it was proposed to make and keep every patient free from
glycosuria and from obvious acidosis. This initial step appeared as a
sufi&ciently radical, even hazardous, departure from the former man-
agement of severe cases; and it was hoped that there might be more or
less improvement in such assimilative function as remained to these
patients, corresponding to the gain in tolerance known to occur when
the symptoms of milder diabetes were cleared up under the old treat-
ment. The reality of such improvement in many of the most intense
cases in their earlier stages is now a familiar fact, and is discussed in
Chapter VII. Even in the first patient, however, the inability to
gain in assimilation to any important degree was manifest, and other
cases quickly confirmed the fact that prolonged severe diabetes was
characterized under this plan by permanently low food tolerance,
and that downward progress was merely delayed and not prevented.
The obvious path for investigation was to determine whether the
degree of functional rest represented by the crude tests originally se-
lected is adequate for such extremely severe cases of diabetes as
were intentionally selected for trial of the treatment; and this also
would have answered the question whether or to what extent there
is a genuinely spontaneous downward progress in diabetes of any
type. At this earliest period, the question was discussed with
Joslin whether it might not logically be required to abolish hypergly-
cemia rather than merely glycosuria, and whether it is possible to
bring the blood sugar to normal in the severest cases. Under the con-
ception of diabetes as a weakness of the total metabolism, it would
have been necessary to carry out simultaneous studies of the carbo-
hydrate, protein, and fat functions; to determine whether overstrain
of any side of metabolism was present; whether such overstrain was
demonstrably injurious; and whether the overstrain and injury could
be obviated. Such' studies upon a few cases would have given an

137

138 CHAPTER n

early answer to the essential question. In the first patients, it was
not possible to perform even blood sugar analyses. With the expan-
sion of laboratory facilities, the therapeutic problem became replaced
by others; and in consequence, treatment was applied to a long
series of patients over a long period of time with no advance over the
original crude criteria. That is, negative sugar and ferric chloride
reactions in the urine were maintained if possible, as originally rec-
ommended; but hyperglycemia, ketonemia, and the excretion of sev-
eral grams of acetone bodies with increased urinary ammonia daily,
as shown in the records, were allowed to continue without investiga-
tion of their possible consequences or the development of any further
means to combat them.

This poKcy has been followed by disastrous results, both in the
present series, and in the experience of others with the same method.
Meanwhile, experiments upon partially depancreatized dogs have
shown similar conditions. After suitable operation, a dog on a given
diet may be free from glycosuria and yet have hyperglycemia. One
of two things happens. Either the hyperglycemia passes off and the
animal lives indefinitely, or hyperglycemia persists, with or without
ketonuria, and the progressive decline duplicates that of corresponding
human diabetics. This outcome in animals which are demonstrably
free from spontaneous downward tendency furnishes decisive proof
that this degree of functional overstrain may of itself produce this
result.

This fact does not conflict with the observation of Mosenthal,
Clausen, and Hiller^" concerning the stubbornness of the tendency to-
hyperglycemia in severe diabetes. For practical reasons, it may some-
times be necessary to allow patients to go along with this level of
blood sugar which assists their defective power of combustion, appar-
ently by mass action. It is surprising how well many patients can.
do under such conditions, and for how long a time. But the down-
ward progress which ultimately follows this overstrain cannot prop-
erly be called spontaneous. Also, the greater the genuine severity
of the case, the more quickly and obviously does this continuous,
hyperglycemia bring disaster. It is belifeved that the utmost effort

^0 Mosenthal, H. O., Clausen, S. W., and Hiller, A., Arch. Int. Med., 1918,
xxi. 93-108.

GENERAL PLAN OF TREATMENT 139

should be made to maintain normal blood sugar at any stage; but
above all, proper treatment demands that a case be so managed from
the earliest diagnosis that the tendency to hyperglycemia shall be
prevented or delayed as long as possible.

The conditions described above do not apply to dogs with pancre-
atic atrophy or to occasional human patients with organic disease
obviously progressive in character and causing decline irrespective of
diet. Time has not yet permitted answering the other half of the
question; viz., whether the great mass of typical diabetic patients are
ultimately subject to downward progress even when all functional
overstrain is relieved as far as ascertainable.

As shown in Chapter VII, results have been decidedly best when
early cases of diabetes have been so treated as to keep them normal
to all the chemical tests used. In resuming the therapeutic prob-
lem recently, difficulty was anticipated in a large proportion of more
advanced cases, because the hyperglycemia is often very refractory
to fasting. It has proved possible, however, to achieve a normal
blood sugar in almost all cases on a plan prompted by the following
reasoning.

Reduction of body mass has been a regular means of improving
assimilation. But if it were desired only to relieve of his obesity
one of the fat patients in the series, the best method would be neither
plain fasting nor a haphazard mixed diet. The rational diet for
obesity is one containing protein to protect body nitrogen and bulky
vegetables to fill the stomach, while low in calories so as to compel com-
bustion of body fat. An obese person can endure such a treatment,
when on plain fasting he might become dangerously weakened before
his weight was sufficiently reduced. The same considerations apply
with greater force to weakened diabetics. By subjecting these
emaciated patients to an obesity cure, their weight has been reduced
sufficiently to conquer their hyperglycemia. This means, in practical
application, that after the initial fast and carbohydrate test, if the
blood sugar is still high, the patient receives a diet in which the only
real food is protein, generally about 1 gm. per kilogram of body
weight. Body nitrogen is spared and strength maintained better
than on plain fasting, and the program is continued until the blood
sugar falls to 0.1 per cent. The specimen laboratory chart facing

140 CHAPTER n

page ISO illustrates such a treatment, through the periods of the
initial fast, the carbohydrate test, then the protein diet till the blood
findings are normal, and fina,lly the mixed maintenance diet. Rare
cases are so severe that both hyperglycemia and ketonuria persist
for weeks on this exclusive protein diet. Here it has been necessary to
keep the patient for a week or two on a diet with negligible food values,
viz. soup, bran, agar jelly, and thrice cooked vegetables, in order to
obtain normal blood sugar, which may then contmue on the above
protein diet. Protein is increased if possible to 1.5 gm. per kilogram
of weight. The first food added to it is carbohydrate, and a patient,
according to severity, is required to assimilate 5 to 20 gm. without
hyperglycemia, and thus to be free from any trace of ketonuria, be-
fore proceeding to the gradual addition of fat. The limit of fat and
calories in the maintenance diet is governed by laboratory tests.
The importance and interpretation of these tests change in the later
observation period from what they were at the inception of treat-
ment, and a few remarks may be devoted to the three phases of
metabolism involved.

Protein. — No direct tests of protein metabolism are required in the
late observation period. Most important would be total nitrogen
analyses in any case of doubt concerning the nitrogen balance, but
on the protein allowance recommended the patient ordinarily comes
into nitrogen equilibrium with simple clinical observation. Am-
monia is always normal if acidosis is controlled as described. Un-
published analyses in this laboratory have shown that in the most
intense active diabetes there is increase of amino-acids both in the
urine, as reported in the literature, and in the blood; but this, like the
exaggerated nitrogen catabolism, is regularly absent under the
routine treatment. Sufficient warning of an overtaxed protein me-
tabolism is afforded by hyperglycemia or ketonuria.

Carbohydrate.— With. Benedict's method,*^ it is now as easy to de-
termine the sugar in blood as formerly the sugar in urine, and really
simpler and more satisfactory to make the analysis than to send the
blood to a laboratory. One hindrance to its use by practitioners has

" Lewis, R. C, and Benedict, S. R., /. Biol. Chem., 1915, xx, 61-72. Benedict,
S. R., ibid., 1918, xxxiv, 203-207. Bock, J. C, and Benedict, S. R., ibid., 1918,
XXXV, 227-230.

GENERAL PLAN OF TREATMENT 141

been the cost of a colorimeter, which has been met by the introduction
of the Bock and Benedict^' instrument. Epstein' s*^ modification of
the Benedict method, though not quite so accurate, is the sim-
plest and cheapest of all and requires only a few drops of blood, ob-
tainable from the ear or finger. A large number of physicians whose
tests must be made in their own offices and who would never under-
take a more elaborate method, will undoubtedly make use of this
device, and will have no excuse for being without blood sugar analyses.
Knowledge spreads rapidly among diabetic patients, and instead of
objecting to the drawing of blood many of them doubtless will soon
be demanding it.

If the blood sugar is kept normal, urine tests are almost superfluous.
The patient has the agreeable knowledge that glycosuria is always
absent, and his tests merely guard against errors in diet or any un-
foreseen change. The blood sugar is one of the most delicate indi-
cators not only of the carbohydrate but of the total metabolism.
Even though glycosuria be absent, a dangerous lack of control of the
diabetes is indicated in those instances where the blood sugar actu-
ally rises after one or several days of fasting. It is sometimes but not
necessarily associated with a correspondingly unfavorable change in
the acidosis. The h3^erglycemia after carbohydrate ingestion rises
and falls relatively quickly. There is a more gradual rise and fall
after protein. The absence of hyperglycemia after feeding pure fat,
and the slowness of the rise of blood sugar on adding fat to a diet,
are in accord with the accepted belief that fat is not converted directly
into sugar; but the h3^erglycemia is particulatly lasting and stubborn.
The limit of fat in a maintenance diet is reached when hj^erglycemia
results from its further addition to the ration of protein and carbo-
hydrate which has been fixed as necessary. The ideal is that the
blood sugar shall not be above 0.1 per cent fasting or above 0.15 per
cent during digestion.^

*^ Epstein, A. A., /. Am. Med. Assn., 1914, Ixiii, 1667-1668. Instrament with
instructions obtainable from Ernst Leitz, 30 East 18 Street, New York City.

■*'As this monograph goes to press, the first of a sferies of papers from the
laboratory of S. R. Benedict, who has already contributed so preeminently in the
field, are appearing in The Journal of Biological Chemistry, 1918, xxxiv, 195-262.
The application of a newly perfected method, which determines quantitatively

142 CHAPTER n

Fat. — The two direct evidences of disordered fat metabolism are
acidosis and lipemia, which will be considered separately.

Acidosis. — Quantitative tests are necessary precautions when
acidosis exists; but as far as now known, there is no danger from
diabetic acidosis if the nitroprusside test is negative in both urine
and blood plasma." It has proved possible to keep the reaction con-
sistently negative in some of the severest cases of diabetes. A ques-
tion is possible whether strictness to this degree is necessary: whether

the sugar even in normal urine, gives promise of results of the highest importance
in the study of sugar tolerance and carbohydrate metabolism. The prediction
may be ventured that such a refined method will reveal a pathological excretion
of urinary sugar by diabetics with the familiar marked hyperglycemia. In-
vestigation will have to show whether the urine becomes normal for sugar when
the above requirements of normal blood sugar are fulfilled. It is to be empha-
sized that the essential progress and improvement of clinical results must lie in
this direction of finer methods, earlier diagnosis, and stricter control of incipient
abnormalities. Only by such means can the principle of treatment by sparing
a weakened function be carried out successfully.

** Legal (Z. and. Chem., 1883, xxii, 464) first observed that the nitroprusside
reaction (originated by Weyl as a creatinine test) might serve as a test for acetone
and acetoacetic acid. V. Arnold {Centr. inn. Med., 1900, xxi, 417), by fine
quahtative tests showed that acetone is excreted only in the severest grades of
acidosis, while the substance present in ordinary so called acetonuria is aceto-
acetic acid. Embden and Schliep {Centr. ges. Physiol, u. Path. Stqffwecks.,
1907, ii, 289) found quantitatively no preformed acetone in the fresh urine in
some cases of ketonuria, and in other cases it ranged about 1/10 to 1/4 of the total
acetone bodies. Folin and Denis (/. Biol. Chem., 1914, xviii, 267) stated that
"acetone urines contain from two or three to nine or ten times as much aceto-
acetic acid as acetone." Rothera (/. Physiol., 1908, xxxvii, 491) regarded his
improvement of the nitroprusside test as a test for acetone; but W. H. Hurtley
{Lancet, 1913 (1), 1160) proved that with pure materials the Rothera reaction is
sensitive to acetoacetic acid in 1 to 400,000 dilution, but to acetone only in 1 to
20,000 solution. Kennaway {Guy's Hasp. Rep., 1913, Ixvii, 161) confirmed the
fact that the Rothera test is essentially an acetoacetic test which is at least 25
times as deUcate as the Gerhardt ferric chloride reaction; and he suggested that
the greater opportunity and ease of diffusion through the lungs as compared
with the kidneys is the reason why most of the preformed acetone leaves the
body through the former. There is no simple qualitative test for /3-oxybutyric
acid. To some extent the intensity of the acetoacetic reactions serves as a rough
index of the quantity of both acids present, but there are wide departures from
this rule in both directions.

GENERAL PLAN OF TREATMENT 143

normal persons with identical nutrition would not show slight keto-
nuria, and whether it may not be harmless. There is an opposite
speculation whether a diet or metabolic state productive of keto-
nuria is not more or less harmful even to normal persons, and whether
a diabetic may not be more susceptible to injury. The presence of
|3-oxybutyric acid out of proportion to the small acetone-acetoacetic
"fraction seems to characterize some of the long standing severe cases.
Any considerable ketonuria in severe cases is associated sooner or later
-with hyperglycemia. When the blood sugar is low, faint nitroprusside
reactions have been allowed to exist in some patients, without empiric
evidence of harm. While ketonuria is most closely associated with the
fat ration, it can result directly or indirectly from unwise addition of
•any kind of food to the diet. When acidosis in the strictest clinical
•definition is kept absent as described, the plasma bicarbonate is regu-
larly high, generally above rather than below 65 per cent.

Lipemia. — ^The investigation of this subject is apparently of rapidly
;growing importance. It has long been known that some cases of dia-
betes are characterized by lipemia far in excess of anything found in
any other condition. Some of the facts recently established^ are
that the blood fat may be several times the normal without notice-
able turbidity; that the lipoid relations, especially the high cholesterol,
-are in contrast to normal alimentary Hpemia; that in severe diabetes
the hyperlipemia is apparently as constant and characteristic as the
Tiyperglycemia, and that it is largely associated with the fat intake
and with other active diabetic sjonptoms. At present, the findings
•seem to support the conception of diabetes as a disorder of the
total metabolism, and to furnish further evidence against the mis-
leading practice of labelling phloridzin, adrenalin, or other forms of
-sugar excretion as "diabetes." The question immediately arises
whether excess of fat in the blood is not as truly indicative of over-
^strain and injury as excess of sugar. It is also essential to know
whether the rigid program above outUned brings the lipoids as well as
other blood constituents to normal. The work of Gray^^ shows actu-
.ally low levels of blood fat in some severe cases under strict treat-
ment. Many analyses are also under way in this hospital. It is

"Allen, Am. J. Med. Sc, 1917, cb'ii, 313-371. Gray, Boston Med. and Surg.
J., 1918, clxxviii (references to Bloor and Joslin).

144 CHAPTER II

not yet certain whether fat determinations are necessary for guid-
ing treatment at this stage. The blood sugar and nitroprusside tests
may perhaps suffice.

It should be emphasized that comparison and clinical judgment are
necessary in interpreting the significance of all laboratory tests. It is
wholly erroneous to consider that hyperglycemia, ketonuria, or any
other laboratory finding is in itself proof of a breaking strain upon
metabolism, or that absence of such indications gives assurance that
all is well. As in dogs, so in patients, hyperglycemia may gradually
subside on right diet or may gradually develop on wrong diet. The
same is true of ketonuria, and doubtless also of lipemia. Some pa-
tients in this series have been discharged with marked hyperglycemia
and ferric chloride reactions present. These persisted for months,
but yet the policy was safe, because it was recognized clinically that
the cases were essentially mild diabetes, and that these symptoms
would gradually clear up, without requiring that an elderly or weak
person be subjected to more serious privations. Such liberties with
a severe case, even though tlie remaining symptoms be slight, are
risky; and they are disastrous with any case unless the diet is within
the actual tolerance. It is highly important not to treat an incipient
case of potentially great severity as if it were a genuinely mild case.
Also, in some severe cases in this series, the blood sugar was sometimes
brought to normal by withdrawal of carbohydrate, with a diet too
high in fat and calories. More or less ketonuria was present, and
doubtless the blood fat was high. Notwithstanding absence of hyper-
glycemia for weeks or months on carbohydrate-poor diet, such a case
can be expected to go steadily downhill. The character of the case,
comparisons of different tests, and the direction of progress are there-
fore important guides in treatment and prognosis. Too much em-
phasis upon any single test may be as misleading as the lack of tests;
and though laboratory work should never be slighted, the experienced
man with very simple means will administer far better and safer
treatment than the tyro with a great laboratory at his disposal.
The ideal treatment therefore begins with rather extensive laboratory
study, but in the end comes down to a very few simple tests.

While discussing ideals, the fact should be plainly faced that the
program above suggested is for very severe cases an excessively rig-

GENERAL PLAN OF TREATMENT 145

orous one. The patients of this extreme type are weakened by it;
sometimes they must be temporarily kept in bed; and their physical
and psychic depression becomes greatest at about the time the blood
sugar becomes normal. No disaster has occurred under the method,
and none of these patients has refused it. Strength returns when a
maintenance diet is resimied; sometimes it seems as great as before,
but more often the fall in both flesh and strength is noticeable. In
view of the questionable prognosis in such extreme cases at best,
the conservative physician will ask himself whether it is advisable to
impose such privation, especially as inanition and the dangers of
chance infections are obviously brought closer. In a few cases, mod-
erate hyperglycemia and shght nitroprusside reactions without other
symptoms have been permitted in the interests of strength and
efficiency. Similar ideals have suggested themselves to a number of
the best workers in this subject, on account of their similar mishaps
with the less careful methods. As far as known, however, both the
plan and execution of the above program are new. It has been appHed
because the patients wished to live, and because it was certain that
they would die soon unless saved by radical measures. Their sub-
jective comfort after the rigid treatment has been about the same as
before. The downward progress formerly evident has in every in-
stance been either arrested or delayed — the few months of experience
do not permit answering which. It is not certain whether such a
method is to be generally recommended in practice, and in any event
there is no desire to urge it upon either physicians or patients. It is
fairly certain that the rigid plan will prolong life and also maintain
a fixed level of nutrition, if not indefinitely, at least considerably
longer than laxer methods. If hyperglycemia, ketonuria, and other
symptoms are allowed to persist, a definitely gloomy prognosis must
be accepted, and the choice is essentially either death in coma or pro-
gressively more severe undernutrition, which becomes more extreme
than required under the rigid plan and increases to death in starva-
tion. The above quaUfications apply, however, only to these cachetic
patients with excessively severe diabetes. The greatest importance
of the plan lies in its application to earlier cases, and for these it is
strongly and unreservedly recommended. In the early stage it is
shorter and easier to carry out, involves no extreme privation or

146 CHAPTER II

physical deterioration, and fulfills the purpose of relieving metabolic
strain as far as present analytic methods can determine. It has
thus far demonstrably prevented downward progress in several cases
of the type which ordinarily progress downward, and it offers at least
a chance of continued subjective health, whereas looser methods prom^
ise nothing but death.

When the blood sugar is normal, glycosuria from trivial carbohy-
drate ingestion does not occur. Accurate reckoning of the diet is
just as essential; but yet if glycosuria results from slight fluctua-
tions in the carbohydrate content of vegetables, or from adding a few
hundred grams of thrice cooked vegetables, the patient is certainly
too close to the verge of his tolerance and trouble will follow unless
the condition is improved. There are the following reasons for giv-
ing carbohydrate as prominent a place in the diet as feasible. First,
it gives the quickest and most harmless danger signal. Second, at
least a small quantity is necessary to fulfill the ideal of freedom from
ketonuria. Third, it spares protein more effectively than fat, and
incidentally spares the total metabolism somewhat; and as shown by
Zeller,*^ if the carbohydrate of the ration is equivalent to one-tenth
of the fat calories, the sparing is as effective as though all the fat were
replaced by carbohydrate. Fourth, by permitting a supply of fresh
green vegetables, it makes a diet more agreeable and satisf3dng than a
higher carbohydrate-free ration. Fifth, on general principles and for
reasons partly unknown, a mixed diet is the only natural diet, and
no diabetic will ever live long on any other. Caution is needed
against the mistake conamitted by some, in giving so much carbo-
hydrate that a living ration of protein and fat is made impossible.
But as stated, the rule in this hospital recently has been to reduce
the total diet sufficiently to enable any patient to assimilate at least
5 gm. of carbohydrate, and correspondingly more in the less extreme
cases.

Various methods of treatment have been tried in the present
series. At one extreme there has been reversion to the old practice
of carbohydrate-poor diets of 40 calories per kilogram or more.
At the other extreme are a few cases treated according to the rigid

^"ZeUer, H., Arch. Physiol., 1914, 213-236.

GENERAL PLAN OF TREATMENT 147

program last outlined. The results shown are therefore not those of
any one method. The results of different methods should be compared
and the choice of treatment governed accordingly. The experience
is believed to support the original principle that treatment should
aim to spare a weakened total metabolism, and that in proportion as
carbohydrate must be restricted, the total diet should also be kept
low.

VI. Practical Management of Diets.
A. Organization.

Many physicians and hospitals have found it possible to conduct
diabetic treatment more or less successfully under adverse conditions.
Foods may by special arrangements be served from the general kit-
chen if necessary. Though some patients in the present series, es-
pecially in observations requiring accuracy, have been isolated in
individual rooms, others have been in open wards with patients suf-
fering from other diseases. Their own fidelity, and the knowledge
that glycosuria and fasting would follow an indiscretion, have main-
tained a high general average of good conduct.

The ideal arrangement, and the one which is being rapidly adopted
by the best hospitals, is to organize a special diabetic or metabolic
ward, with a separate diet kitchen in as convenient proximity to it
as possible. The kitchen organization here, and the cooperation of
Miss Emmeline Cleeland, the diet nurse, have contributed much to
the success of the work.

The head of the kitchen may be either a specially quahfied nurse
or a trained dietetian who is not a nurse. Her time is best left
free for duties of supervision. The physician has merely to order a
diet in terms of protein, carbohydrate, and calories. The nurse then
translates these figures into the actual foodstuffs, superintends the
cooking, and is responsible for the accurate recording of everything
pertaining to the diet. She maintains a sympathetic acquaintance
with all patients, takes care that the selection and preparation of food
suits their tastes as well as possible, and by smoothing small diffi-
culties contributes greatly to lighten the lot of the patient and the
labor of the physician. Under some circumstances it may be con-
venient for one nurse to have charge of both the kitchen and the
ward, and to supervise also the qualitative testing and recording of
the urine.

The assistant diet nurses vary in number with the number of
patients and the degree of detail required. Labor is saved at the

148

GENERAL PLAN OF TREATMENT 149

expense of some slight inaccuracy by weighing certain foods after
cooking, by estimating certain other foods, etc. Servants at lower
wages can save both the nurses' time and some of the more dis-
agreeable features of the work. In this hospital every kind of food
has been weighed accurately raw, and cooked separately for each
patient. With this arrangement, one assistant nurse for about eight
patients has been needed. If the service is rotating, an assistant
nurse should if possible spend at least three months in the kitchen con-
tinuously; otherwise both time and accuracy are sacrificed in teaching
new nurses. At the end of the three months she should be familiar
not only with the cooking but also with the duties of the head nurse.

B. Equipment.

The equipment is mostly that of an ordinary kitchen. A few
special articles have been found useful, as follows:

Diet scales. — An accurate spring balance has been used for weighing
the individual food portions. In construction it is similar to the or-
dinary letter scales. This model is manufactured* by Chatillon and
Company, 85 Cliff Street, New York. The price, formerly $5.00, is
now $7.50. Each patient buys such a balance preparatory to return-
ing home. The dial is movable, so that it can be set at zero after
the dish for receiving food is placed on the weighing stage. The
weight of the food can then be read directly in grams. The quickness
and convenience of such an instrument is important for prolonged
fidelity in weighing food, for few patients will trouble themselves
through months and years with the tediousness of ordinary scales
and weights.

Steamer. — A well known form of steam cooker has been used for
cookirig vegetables without loss of carbohydrate. The reservoir at
the bottom contains water; the compartments above hold the vege-
tables. As the steamer is constructed on the unit system, few or
many of the compartments may be used at any time as needed. By
this means a number of different vegetables can be steamed simul-
taneously, and the more easily cooked ones can be removed before
the others.

Slide Rule. — Nurses who are to calculate many diets can save time

150 CHAPTER n

and trouble in multiplication by learning to use a simple slide rule.
A convenient one is the "Merchant's," obtainable from the Keuffel
and Esser Company, 127 Fulton Street, New York City.

Adding Machine. — ^Additions have been performed with the Golden
Gem Adding Machine, manufactured by the Automatic Adding
Machine Company, 148 Duane Street, New York City. A small and
inexpensive instrument of this sort aids not only in time-saving but
also in accuracy.

Records. — ^A twofold record of diets has been kept. A more de-
tailed separate diet chart shows each individual food item for each
meal, together with the totals, as illustrated in the specimen diets
hereafter. A statement of the totals for the day is also entered in
the laboratory chart, in order that the relation between diet and
laboratory findings may be evident at a glance.

One general form of laboratory chart has been used since the early
organization of the work, with slight modifications as needed from
time to time (Table III). It measures 30 by 90 cm., and folds so as
to conform to the clinical charts. In the table two figures are given
for carbohydrate, protein, and fat for each day. The upper figure (in
bold face type) denotes calories, the lower figure (in ordinary type)
grams. For convenience in entering on the chart, the two figures
are written in the form of a fraction; the figure above the line
(calories) is written in red ink, that below the line (grams) is
written in black ink. Formerly there was a column for alcohol,
but this has been dropped, and if alcohol is given on any rare occasion,
it is written into the total calory column. There also was formerly a
column for sodium bicarbonate, but as this is so seldom used, the
column has been discontinued and any occasional doses of alkali en-
tered in the "Remarks" colimin. Among foods, three colimms are
found under "Bacon," the abbreviations indicating the three forms
in which it is served; first whole bacon; second crisp bacon, fried so
as to reduce the fat content as low as possible; third the clear bacon
fat, practically free from protein. These three forms serve different
purposes, and yet the advantage of the bacon flavor is retained. The
two columns under vegetables show the total weight respectively of
carbohydrate-containing or thrice cooked kinds. The various "Re-
marks" columns give room for additional analyses or special notes,
explanations, time of day, etc.

GENERAL PLAN OF TREATMENT 151

C. Notes on Special Features of the Maintenance Diet.

1. Fast-Days. — Occasional single days of fasting or greatly reduced
diet have been prescribed in the after-treatment of all cases. They
are taken at regular fixed periods, the length of the interval and the
rigor of the program being proportioned to the severity of the diabetes.
In the typical severe cases, a fast-day is taken once each week, the
patients generally choosing Sunday for the purpose. In even the
mildest cases, such a day is ordered at least once a month, more
commonly once every 2 weeks. Individuals react differently. Some
go about their usual affairs; others are comfortable in bed; others
become weak and depressed. When discomfort persists even after
habituation, and in any mild case when desirable, the ordeal is miti-
gated if possible. The addition of a few hundred grams of thrice
cooked vegetables to the bran, soup, and coffee of an ordinary fast-
day may give relief. Especially in milder cases, vegetable days are
useful; not the old fashioned kind with fat and other additions, but
only vegetables containing such carbohydrate as will not raise the
blood sugar above 0.15 per cent and will leave it not above 0.1 per
cent on the following morning. Protein and other foods necessarily
diminish the benefit of a fast-day in proportion as they are allowed.
Von Noorden's designation of fast-days as "metabolic Sundays" is
suggestive. There is no evidence whether the same number of calories
weekly will be borne any differently if distributed over 7 or 6 days.
But as the body in other respects seems to function more efficiently
by working 6 days and resting 1, it is possible that a similar prin-
ciple may apply to metabolism; also, the patient may perhaps feel
and work better if he takes the larger ration on 6 days and relaxes
as completely as necessary on the 7th. The occasional relief from the
metabolic burden may also be beneficial in even the mildest cases, in
guarding against downward progress and in atoning for any chance
indiscretions. Such days of special restriction are also a strong re-
minder of the existence of diabetes and the need of continuous precau-
tion, so that they aid instead of hindering discipline. Regular fast-
days are intended for prevention of symptoms. When fasting is
compelled by the actual occurrence of glycosuria or hyperglycemia,
the diet is wrong and must be changed. ,

152 CHAPTER n

2. Water. — There is no objection to mineral waters, but they are
without special virtues and are unnecessary when good plain drink-
ing water is available. Mineral springs and resorts should be rated
solely according to the efficiency of their dietetic treatment, and in as
far as curative influence is attributed to the water they constitute an
unfavorable environment.

3. Alcoholic Beverages. — As stated, all alcohol habits are best dis-
couraged, and as the calories of alcohol must strictly be counted in a
limited diet, the patient will generally prefer more wholesome food.
Light wines, as low as possible in both carbohydrate and calories, are
probably best for those with whom alcoholic beverages are a habit
too firmly fixed to be broken.

4. Coffee or Tea.— The use of weak tea or coffee, or Kaffee Hag, not
more than three cups daily, has already been mentioned as permis-
sible with fasting or any diet, except that a coffee habit has not been
cultivated in persons not addicted to it. Joslin often substitutes a
drink made of cocoa hulls.

5. Milk. — Sugar-free milk of satisfactory taste is prepared by
D. Whiting and Sons, 570 Rutherford Avenue, Boston, Mass., and its
keeping qualities are such that it can be shipped long distances.
Little use has been made either of it or of home-made preparations of
casein and washed cream (i.e. cream mixed with large volumes of
water to remove lactose, and skimmed off after rising or centrifuga-
tion). Milk is important for children, but it is considered the best
policy to regulate their total diet so as to create sufficient carbohy-
drate tolerance to enable them to take natural milk. Sugar-free
milk would thus be needed only temporarily, or as part of the diet of
diabetic infants.

6. Soup. — Thin soup made from bones or stock contains very little
nutrition, but its warmth and flavor are highly gratifying, and it also
supplies salts, and aids in serving bran biscuits, thrice cooked vege-
tables, and other articles having httle taste. It has been allowed in
quantities of 300 to 600 cc. daily, during fasting, carbohydrate tests,
and all other diets. Sometimes beef tea, made from beef extract,
has been used as a means of avoiding even the small quantities of
protein of ordinary soup.

GENERAL PLAN OF TEEATAIENT 153

7 . Salt. — Probably because of the rather monotonous and unsatis-
ifying diet,' patients with severe diabetes often crave surprising quan-
tities of salt. Many of them develop edema on unrestricted salt
intake. The susceptibility of individuals differs. Though no real
harm has been seen from the edema, salt-free diet has sometimes
temporarily been necessary to remove it, and for all severe cases
sodium chloride is given in a weighed daily allowance like other
items in the diet. The limit has commonly been 5 gm. daily; some-
times only 3 gm., occasionally as much as 8 gm. Numerous glass
tubes containing such weighed quantities of salt are kept on hand
in the diet kitchen. The nurse uses a part of the day's allowance for
seasoning, and the rest is placed in a small salt shaker on the pa-
tient's tray, to be used at his discretion with one day's meals. The
craving is generally not noticed when limitation of the supply pre-
vents forming the abnormal habit.

8. Meats. — Meats are included in the diet according to their food
value and the tastes and digestion of the patient. Eggs and vegetable
proteins are available on the same basis. No indications of specific
differences between proteins and no advantages in vegetarianism have
been observed. For a low protein vegetarian diet, it would be neces-
sary to use care in selecting the kinds of protein, to assure an adequate
supply of all indispensable amino-acids.

P. Fats. — These are chosen on a similar basis of suitability; There
is no need to pay attention to the content of higher or lower fatty
acids from the standpoint of ketonuria. If anything, butter is pref-
erable to olive oil.

10. Raw and Steamed Vegetables. — Since carbohydrate is desirable
in the diet, it is obviously preferable to use vegetables without ex-
traction when possible. Even ordinary boihng is a partial extraction.
Therefore, for accurately retaining the food value, vegetables have
been served either raw or steamed in the steamer above described.
Additional mention may be made of canned vegetables, which are
used either in this way or after thrice cooking if necessary. Canned
or dried vegetables are important aids to the winter diet.
Patients sometimes prepare their own supply in summer. The ad-
vantage of giving carbohydrate in the pleasant, varied, bulky, and
satisfying form of vegetables, rather than in smaller quantities of

154 CHAPTER II

bread or cereals, is obvious. With green vegetables, eggs, butter,
etc., there should be no fear of a lack of vitamines or other accessory
substances in the diabetic diet.

11. Thrice Cooked Vegetables. — ^Whatever time a vegetable requires
to cook is divided into three approximately equal periods, and the
boiling water changed so as to make three extractions of carbohy-
drate. Each patient's portion is made ready for cooking as usual,
weighed raw, and tied loosely in a single layer of cheese-cloth, and
the portions for different patients thus boiled together in one large
pot. The thrice cooked vegetables have been used to contribute
bulk with negligible food value. They are so important for this
purpose that the treatment would in some cases be almost impossible
without them, and they -add much comfort in other cases not quite
so severe. The different kinds of vegetables vary in the degree to
which they retain their flavor, but most are palatable and some are
practically as appetizing as with ordinary cooking.

Their empirical use without analyses has entailed some uncertainty
and inaccuracy in the present series. Such analyses before and after
boiling or extraction have been made by Wardall.*' There is always
a question in interpreting such figures. The cellulose of which
vegetables are largely composed is a carbohydrate, but indigestible.
On the other hand, if starch and soluble carbohydrates are alone
considered, there is a question whether other substances present may
not become potential sugar-formers upon digestion. Furthermore it
is possible that more or less starch inclosed within cellulose may not
be utilizable. Phloridzinized animals could scarcely furnish fully
conclusive results. Accordingly an empirical element remains, and
numerous patients in the present series have had sufficiently severe
diabetes that extracted vegetables could not be taken without limit.
The empirical observations have closely agreed with Wardall's chemi-
cal proof that spinach, celery, and asparagus are the safest for this
purpose. Cabbage, cauliflower, Brussels sprouts, and onions retain
enough carbohydrate to cause glycosuria much more readily than the
three first named. If only 1 per cent absorbable carbohydrate
should remain, and if a kilogram of the vegetables should be given in a

" WardaU, R. A., J. Am. Med. Assn.. 1917. box, 1859-1862. See also Joslin's
text, 2nd edition, p. 261.

GENERAL PLAN OF TREATMENT 155

day, it is clear that such carbohydrate content is important for a
patient whose actual tolerance may be 5 gm. or less. As previously
mentioned, this state of excessively low tolerance ought not to be
allowed to persist; but nevertheless carbohydrate should always be
reckoned as accurately as possible. There is no reason why patients
whose tolerance is a little greater should not, at least for occasional
variety, receive higher class vegetables which have been extracted
to reduce their carbohydrate content; but analyses such as those of
Wardall will be necessary before they can be used with accuracy.
What can be done with fruits in this direction will also bear further
investigation.

Besides a little carbohydrate, thrice cooked vegetables convey more
or less salts, and may have some real importance in this respect.
Blunt and Otis*' found that spinach loses 50 per cent, string beans
43 per cent, navy beans 39 per cent, peas 36 per cent, and potatoes
22 per cent, respectively, of their iron in cooking. Salts of potassium
and heavy metals are also furnished in utilizable form by such vege-
tables. Courtney, Fales, and Bartlett*' investigated the salt content
of vegetables boiled so thoroughly as to be comparable to the thrice
cooked kind. Tables IV and V are reproductions of two of their
tables.

This large loss of salts occurred in the first few minutes of boiling;
for example, spinach boiled only 10 minutes had already lost 42.2
per cent of its ash; the very prolonged further boiling had relatively
little effect. These authors confirm the well known marked predomi-
nance of bases over mineral acids in vegetables, and the assimilable
character of these bases, which are probably in combination with or-
ganic acids. It is possible that the very high plasma bicarbonate
(above rather than below 65 per cent) so often, found in severe cases
under rigid treatment may be attributable to the vegetable diet.
With the customary liberal use of vegetables, diabetics should certainly
suffer no lack as respects quantity, variety, or assimilability of the
supply of mineral bases.

** Blunt, K., and Otis, F. A., J. Home Economics, 1917, ix, 213-218; Chem.
Abstr., 1917, xi, 2124.

*' Courtney, A. M., Fales, H. L., and Bartlett, F. H., Am. J. Dis. Child..
1917, xiv. 34-39.

156

CHAPTER n

For practical purposes, thrice cooked vegetables (generally spinach,
celery, and asparagus) have been used in limited quantities without
any food value being reckoned for them. The protein of green vege-

TABLE IV.
Content in Gm. of Solids of 100 Gm. of Vegetables Erepared by Boiling.

Vegetable.

Spinach. .
New-
Zealand
spinach.
Young. . .
carrots
Onions.. .
String

beans. .
Aspara-
gus. . . .
Potatoes.

90

30

30

45

ISO

30
30

Solids.

.30

4.26

6.31
6.82

5.31

4.59
20.51

Ash.

1.172

0.535

0.408
0.398

0.371

0.370

CaO

0.305

0.145

0.039
0.020

0.070

0.038

MgO

0.035

0.021

0.014
0.013

0.030

0.021

PjOb

0.123

0.052

0.043
0.067

0.063

0.101

CI

0.036

0.000

0.023
0.008

0.045

0.024

KsO

0.238

0.157

0.181
0.186

0.123

0.174

NaaO

0.068

0.040

0.038
0.010

0.011

0.001

HjSOi

0.034

0.016

0.022
0.056

0.025

FezOj

0.0090

0.0154

0.0070
0.0026

Tr.

0.497

0.236

0.108
0.189

0.190

0.283

i

3 1

3.10

1.48

0.67
1.18

1.19

1.77

TABLE v.
Percentage Lost in Water under Ordinary Boiling Conditions.

Vegetable.

3

JZ

^

9

61.5
81.0
41.6
10.6
54.1
40.1

2

o

<2

9

61.1
77.8
48.8
0
56.3
Tr.

57.2
78.7
49.9
31.6

52.1

6

28.2
50.8
Tr.

U

Tr.

a;

Sninacli . , ;

90
30
30
45
150
30
30

32.2
41.3
37.5
22.5
31.8
27.4
4.4

45.2
72.2
47.8
28.0
43.4
46.7

Tr.

3.6
28.4
26.1
21.4
26.6

48.2
70.2
34.6
24.6
42.7
34.6

71.1
100.0
57.1
31.4
46.8
46.4

64.8
81.9
47.3
29.2

55.2
49.2

?3 1

New Zealand spinach.. . .
Youner carrots

22.3

?? 7

Onions

19 8

Striner beans

?6 7

Asnaraffus

?4 1

Potatoes

tables is known to be poorly absorbable.^" Irrespective of any food
content, diabetics should not be allowed to gorge themselves on these
extracted vegetables. Those on reasonably liberal diets do not need
them at all. The allowance for any patient is generally not more

5" Rubner, M., Berl. klin. Woch., 1916, No. 15.

GENERAL PLAN OF TREATMENT 157

than a kilogram per day, and less in proportion as ordinary vegetables
can be used. Excessive quantities are a useless burden upon both
the purse and the digestion.

12. Fruits. — Fruits are the best diabetic desserts, when they can be
tolerated. Most patients can take at least grape-fruit. Within
reasonable limits, there is no prejudice against fruits because of their
carbohydrate being largely in the form of sugar. Neither is there a
favorable bias because so much of the sugar is levulose, for in the long
run the actual carbohydrate and total food values are probably the
determining factors of a diet. Reference must be made to text-books
for the proportions of different carbohydrates in fruits. The latest
article that has chanced to come to notice is that of Eofi," showing
that 52 to 75 per cent of the sugar in apple juice is levulose.

13. Nuts. — Some nuts resemble prepared diabetic foods in their low
carbohydrate and high protein and fat content. They must be used
with corresponding caution. No superior assimilation for nuts or
other less common foods has been observed.

14. Unusual Carbohydrates and Abnormal Modes of Administration. —
Notwithstanding more or less deceptive appearances of assimilation,
little or no practical value is to be expected from caramel, pentose,
7-carbon sugars (hediosit), or other unusual food elements. Like-
wise no hope should be entertained of any special assimilability of
glucose given by rectum or other abnormal way. It need only be
noticed that no patient was ever saved from either starvation or coma
by such means. Confusion will be avoided by recalling the faulty
theory underlying such attempts. In acidosis, the only lasting benefit
must come from relief of the metabolism which is breaking down, by
reducing the diet especially in fat, and not from the introduction of
strange compounds. In nutrition, the level of total diet and weight
determined by the actual assimilative power is a limitation which
cannot be cheated by artificial devices.

15. Bran Bread or Biscuits. — These are the only form of bread
substitute used for the type of cases treated in this hospital. In
milder cases bran can be used in various ways; for example, bread can
be made of eggs, fat, and bran, or bran can be mixed with ordinary

" Eoff, J. R., J. Ind. and Eng. Chem., 1917, ix, 587-588.

158 CHAPTER n

flour to lower the carbohydrate and food value of the latter. But
while severely diabetic patients crave some form of bread, they do not
wish to devote any of their scanty protein or fat to this use. Accord-
ingly the following recipe was developed for a bran-agar bread
having no appreciable food value.

Bran Biscuits.

Bran, weighed dry 60 gm.

Agar-agar, powdered 6 "

Cold water ; 100 cc.

The bran is tied in cheese-cloth and hung under the cold water tap
to wash (with stirring or kneading as required) until the water
runs through clear. The agar is mixed in 100 cc. water (cold) and
brought to the point of boiling. The agar solution (hot) is then
added to the washed bran. The mixture is molded into three cakes
and placed in a pan and when firm and cold baked until dry and crisp.
Salt may be included in the recipe if desired. The biscuit or muffin
shape may be chosen, but it has generally been preferred to make thin
flat pieces like well browned toast. The toasting helps the flavor a
little, and the dryness facilitates keeping.

The chief caution is necessary in the choice of bran. Ordinary bran
flours or breakfast foods are high in carbohydrates. Some kinds of
cheap bran contain middlings or other carbohydrate admixture. It is
possible to buy purified bran, such as Kellogg's. But the bran
ordinarily used for feeding cattle, which on inspection is seen to con-
sist of coarse flakes of the outermost hull of the wheat, is obtain-
able very cheaply at feed stores, and is perfectly satisfactory when
washed under the cold water tap for half an hour or more as above
described.

Some patients like these tasteless bran rusks at once; others either
accept or enjoy them after becoming used to them. They are best
served hot, like toast, with butter, bacon fat, a fried egg, or even
soup, to give them flavor. Besides contributing bulk, like the vege-
tables, the bran is stiU more active in favoring catharsis, and since its
introduction the traditional constipation of diabetic patients has
been almost unknown in this hospital. A few individuals cannot
take the bran; in others sometimes indigestion or diarrhea limits the

GENERAL PLAN OF TREATMENT 159

amount. On general principles, an inert substance should not be
taken to excess, and accordingly the allowance is generally no more
than one or two of the above cakes at each meal.

Bran has never been responsible for glycosuria in this hospital,
and is probably not digested to any important extent. The chemis-
try of bran, especially from the standpoint of digestion, is not thor-
oughly known. It is poor in cellulose (2 to 4 per cent in most analy-
ses), and from its richness in protein and amides, phytin and other
complex compounds, might supply the body with much nitrogen and
phosphorus if digestible. Guareschi^^ states that bran milled to an
impalpable powder is 91 to 92 per cent digestible, and emphasizes its
value for food and for vitamines. The fine milling therefore defeats
the purpose for which bran is used in diabetes.

16. Proprietary Foods. — So called "diabetic" and "gluten" prepa-
rations have largely fallen into disrepute because of the rankly fraudu-
lent character of so many of them. It is still very common for pa-
tients to announce that as soon as diabetes was discovered they be-
gan to eat gluten bread, with or without a doctor's orders; but knowl-
edge on the subject is increasing, and it is becoming generally known
that a physician should at least never order such a food without
specifying a reliable brand.

The medical profession is indebted to Professor John P. Street for
the most complete analyses of diabetic foods. The results are obtain-
able in the publications of the Connecticut Agricultural Experi-
ment Station, especially the report for 1913, Part 1, with added analy-
ses in the report for 1914, Part 5, and the report for 1915, Part 5.
These data are the best basis for the choice of a diabetic preparation.
With improved technical methods, the best brands have been brought
to a high state of perfection from the standpoint of carbohydrate-
ireedom and agreeable taste. Without invidious distinctions, men-
tion may be made of American made examples of the three principal
classes of such foods; viz., gluten flour, which is manufactured in high
purity by Hermann Barker, Somerville, Mass.; casein flour and
muflSns, as prepared by Lister Brothers, 110 West 40th Street, New

^^ Cf. Guareschi, I., Ind. ckim., min. e metal.; 1917, iv, 97-103; Chem. Abstr.,
1917, xi, 2124. Holmes (Holmes, A. D., U. S. Dept. Agric, Bull. 751, 1919) has
obtained a coeflScient of digestibility of only 45 per cent for finely milled bran.

160

CHAPTER n

York City; and soy bean flour, one brand of which is made by the
Cereo Company, Tappan, New York, while the most extensive use
of soy beans by diabetics at present is in the form of the "Hepco"
flour, dodgers, etc., made by the Waukesha Health Products Com-
pany, Waukesha, Wisconsin. For complete hsts and analyses of such
foods, reference must be made to Street's reports or Joslin's text-book.

The essential objection to all such bread substitutes is that in ab-
sence of carbohydrate, they have necessarily been composed of pro-
tein and fat, and thus have represented highly concentrated forms of
food. Both physicians and patients have often viewed these breads
as harmless, or even commendable by reason of their high protein and
food value. The great amount of protein and calories that can be sO'
easily and inadvertently consumed in this way is capable of tre-
mendous damage. Janney^' has pointed out that the potential car-
bohydrate represented in the protein often exceeds the total carbohy-
drate of ordinary bread. It is necessary to warn strongly against this-
indiscriminate misuse of even the best preparations, in which the
manufacturer is not to blame. There is no objection to making upi
as large a proportion of the diet as desired from these flours, provided
the total diet is accurately reckoned and restricted as usual. For cases,
of the grade of severity treated in this hospital, the use of such prepa-
rations has been abandoned, simply because the patients prefer to
take their protein and fat in meat, eggs, bacon, butter, etc., rather
than in flour or bread.

Because of the very limited quantity of these concentrated foods-
which can safely be included in any diet, and because of the danger-
ous ease with which patients can be tempted to overstep their real
tolerance by taking only a small quantity in excess, the manufacturers-
of some of the better brands are moving in the direction of reducing;
the undesirably high food value by the introduction of some indigesti-
ble substitute for carbohydrate. A non-utilizable flour might be
employed in three ways; first, to dilute ordinary flour for mild cases,
so as to reduce the carbohydrate and food value of wheat, corn, or
other bread; second, to dilute the special diabetic flours, so as to make
them permissible more often and in larger quantities, Fhile at the same-

" Janney, N. W., Arch. Int. Med., 1916, xviii, 584-605.

GENERAL PLAN OF TREATMENT 161

time probably reducing their cost; third, for making an entirely non-
nutritious bread substitute, perhaps finer and more agreeable than the
bran bread. An extreme illustration of the feasibility of the use of a
non-nutritious flour can be gained by making a batter with egg, spices,
and impalpable talcum powder, and frying it crisp. This will appear
more satisfying than the egg fried alone. While talcum is inert and
harmless, it is scarcely to be recommended for eating, and a non-
utilizable flour for practical use is most likely to be found in the
vegetable kingdom, probably in some form of cellulose or other
polysaccharide.^* Ridicule or opposition may be aroused by sug-
gestions of flour from cotton, peanut-shells, corn-pith, etc., and the
technical difficulties also have thus far baffled manufacturers. The
German experience in the recent war, that large quantities of wood
flour may cause intestinal disturbance, was confirmed in one short test
with diabetics; but the long experience with bran and shorter trials of
other indigestible substances have shown that the prudent use of these
is safe and practicable. Critics should bear in mind the following
facts: first, it is generally conceded that the food of civilized man is
overconcentrated, frequently excessive, and subject to improvement
by an admixture of indigestible material, as in coarse vegetables;
second, the diabetic flours which it is proposed to dilute are dry pro-
tein-fat powders representing an unnaturally concentrated form of
food; third, diabetics must be more closely limited in their total food
intake than normal persons, and yet they have the usual, even if not
an excessive craving both for bread and for bulk.

D. General Scheme and Specimen Diets.

Two general plans, are possible for diabetic diets. The one which
has been customary in the past has aimed to give the patient substi-
tutes as nearly as possible resembling the accustomed dishes which
he must forego. Accordingly, diabetic cook-books have been fflled

^* Concerning some indigestible carbohydrates, see Mendel, L. B., Ceniralbl.
ges. Physiol, u. Path. Stoffwechs., 1908, iii, 641-654. Mendel, L. B., and Swartz,
M. D., Am. J. Med. Sc, 1910, cxxxix, 422^26. Swartz, M. D., Tr. Connecticut
Acad. Arts, and Sci., 1911, xvi, 247. Concerning the German experience with
wood flour, see Salomon, H., Wien. med. Woch., Dec. 15, 1917 (favorable), and
Neumann, R. O., Vrtljschr. gerichll. Med., 3rd edition, li, pt. ii, (unfavorable).

162 CHAPTER II

with composite recipes, carbohydrate-free puddings, saccharine sweet-
ening, imitation milk, and a host of similar artifices. The most con-
venient way to manage such a diet accurately is to weigh out the
day's allowance of eggs, fat, etc., in the morning and use for cooking
the different meals as required. It may be urged that habits of food
are hard to break, and that a diabetic should not be deprived of
gustatory pleasure xmnecessarily. It may be objected on the other
hand that such diets tantalize and tempt more than they satisfy;
that saccharine keeps aUve the taste for sugar, that the liabiUty to
carelessness is increased, and that a patient does best to face squarely
the fact of his diabetes and the necessary restrictions, and to resolve
to eat to hve rather than Uve to eat, especially since care in diet is the
means whereby all the other pleasures and advantages of the world
are opened to him in fullest measure.

It is generally beheved that the plainest and simplest diets are the
most wholesome for mankind in general. It has therefore been consid-
ered inadvisable to take such great pains to depart from such a diet
for diabetics. Not only is simpHcity highly important for accuracy,
fidehty, convenience, economy, and healthful habits, but in the long
run the simple diet has proved the most satisfying and the least irk-
some. The patient begins such a Spartan regime immediately after
his initial fast in the hospital, when anything tastes good, and by the
time he leaves the hospital his new habit of diet is estabhshed. With
simple menus and a balanced ration, diabetics are free from abnormal
cravings, and natural himger on reduced diets is also easier to appease.

Simplicity does not mean unpleasantness to sight or taste. Here the
skill of the diet nurse or cook comes into play. The refinement of
the table service, even though not expensive, has its esthetic value.
Salads and other simple dishes can be made attractive in appearance.
A single egg can loom surprisingly large to the eye if beaten into a
fluffy omelette or souffle. Variety in cooking and combining the
same foods varies them to the taste. Vegetables offer variety in soups,
and the different ways of serving meat are well known. Eggs, bacon
grease, meat, or the juice from meat give variety and taste to thrice
cooked vegetables, and even to bran muffins. There is no inherent
objection to condiments or spices, but these, except salt, have been
little used, since the diabetic appetite generally needs no stimulation,

GENERAL PLAN OF TEEATMENT 163

and the simple taste of plain foods is sufl&ciently appreciated. Coffee
lovers generally learn readily to like their drink black, without sac-
charine. A little fruit is a sufficient dessert in most cases. The de-
sire for cake, puddings, and other luxuries is discouraged by disuse.
Exceptions have been made only in some extremely severe cases on
minimal diets, since small treats mean so much to these patients.
Agar jelly, ices, sherbets, etc., can be flavored with saccharine, coffee,
wine, brandy, fruit juices, or sugar-free caramel (the quantities re-
quired being very small). Likewise agar with soup or beef extract
makes an agreeable meat jelly. Such tricks often eke out a low diet
or reheve a hard fast-day in the worst cases; but the better fed class
of patients do not need them.

The physician who cannot calculate diets to suit his individual cases,
but is dependent upon text-book menus, will not be able to substi-
tute celery or spinach when one or the other is disliked, and will oc-
casionally meet patients who know more about diets than he. Any-
body who has a list of food values and can use the decimal system can
easily make up the simple diets required by diabetics. The unwise
complexity of dishes in the past has doubtless been largely respon-
sible for the unfortunate helplessness of so many physicians in this
regard. The use of the metric system is not a difficulty but a great
convenience, and it can be learned in a few minutes by those un-
accustomed to it. Though the energy value of carbohydrate and pro-
tein is 4.1 calories per gm., and of fat 9.3 calories per gm., it is suffi-
ciently accurate for ordinary purposes to reckon them as 4 and 9
calories respectively.^^ One elementary example should make the
method clear. .

Suppose that a patient's weight is 50 kilograms, that his tolerance
in the carbohydrate test was 180 gm., and that he is to be given a
mixed diet containing one-sixth of this maximal carbohydrate toler-
ance, together with 1.5 gm. protein and 30 calories per kilogram.

^^Food chemists are well aware of the technical considerations which make
absolute exactness impossible in the ordinary reckoning of a diet. A practical
point is that the number of calories obtained by multiplying the total grams of
protein, carbohydrate, and fat by the proper factors, and the number found by
adding up the calories given in food tables for the individual meats, vegetables,
and other foods served, are seldom identical. Either method is permissible.

164

CHAPTER n

One-sixth of the carbohydrate tolerance of 180 gm. is 30 gm. Any
desired vegetables are selected from food tables to make up this total
of 30 gm. for the day, and divided between the meals at will. The
protein, fat, and calories in the vegetables chosen must be reckoned,
which will give a result such as shown in Table VI.

TABLE VI.

Food.

Carbohy-
drate.

Protein.

Fat.

Breakfast.

Canned asparagus

gm.
150

50

37
148
142

50

150

86

gm.

4.2

1.7
1.1

5.0

5.5

1.7
5.9
5.0

gm.
2.3

0.7
0.5

2.2

1.1

0.7
1.2
1.4

gm.

0.2

0.2

0.1
0.5

0.2
0.6
0.6

Dinner.

Lettuce

Celery

Canned Brussels sprouts

Raw tomato

Supper.

Lettuce

Raw tomato

Cauliflower

Gm

30.0
120.0

10.0
41.0

2.4
22.3

Calories

18"?

TABLE VII.

Food.

Protein.

Fat.

Breakfast.

Eggs

gm.

100
50

57
25

100
50

gm.

14.8
5.0

18.3
6.5

14.8
5.0

gm.

10.6
33.6

2.5
7.9

10.6
33.6

Bacon

Dinner.

Roast chicken

Cream cheese

Supper.

Eggs

Bacon

Gm

64.6
258.0

98.8
899.0

Calories

1157.0

GENERAL PLAN OF TREATMENT

165

Taking up next the protein allowance, this, at l.S gm. per kilogram
for a weight of SO kilograms, will amount to 75 gm. of protein. Since
10.4 gm. of protein is contained in the vegetables already chosen,
this leaves 64.6 gm. yet to be supplied for the day (Table VII).

TABLE

VIII.

■

Food.

Carbo-
hydrate.

Protein.

Fat.

Bueakfast.

Eess

gm,

100

50

ISO

5

57
10
50
37
148
142
25

100

50

9

50

150
86

cc.

150
150

150
150

150
150

4.2

1.7

1.1

5.0

5.5

1.7
5.9
5.0

gm.

14.8
5.0
2.3

18.3

0.7
0.5
2.2
1.1
6.5

14.8
5.0

0.7
1.2
1.4

gm.

10.6

33.6

0.2

4.1

2.5
8.2
0.2

0.1

0.5
7.9

10.6
33.6
7.4
0.2
0.6
0.6

Bacon

Canned asparagus

Butter

Bran biscuits (2)

Coffee

Clear soup

Dinner.

Roast chicken

Butter .

Lettuce

Celery

Canned Brussels sprouts

Raw tomato

Cream cheese

Bran biscuits (2)

Kaffee Hag.

Clear soup

Supper.

Eggs

Bacon

Butter . .

Letituce

Raw tomato

Cauliflower

Bran biscuits (2)

Kaffee Hag

Clear soup

Gm

30.0
120.0

75.0
300.0

120.6
1085.0

1505

A ration of 30 calories per kilogram for a weight of 50 kilograms
means 1500 calories for the day. Since the foods chosen for carbo-
hydrate and those chosen for protein together represent 180+1157 =

166

CHAPTER n

1337 calories, this leaves 163 calories yet to be supplied in the fonn of
fat. It is now necessary to divide the 163 calories by 9, thus showing
18 gm. as the quantity of fat needed. This could be supplied by 18
gm. of olive oil, or 24 gm. of butter, or the equivalent in any other
fat. The total diet for the day is shown in Table VIII.

The specimen diets in Tables IX to XV are given as suggestions.
In them, the factors 4.1 and 9.3 are used, as customary in this
hospital.

TABLE rx.

Carbohydrate Tolerance Test.

A Day's Diet with 30 Gm. Carbohydrate.

Food.

Breakfast.

Canned asparagus

Coffee

Clear soup

Dinner.

Lettuce

Celery

Canned Brussels sprouts.

Canned okra

Clear soup

Kaffee Hag.

Supper.

Lettuce

Raw tomato

Spinach

Canned okra

Clear soup

Kaffee Hag.

m

Calories.

ISO

25

75

150

65

25
ISO
200

66

150
150

150
150

150
150

FFotein.

2.3

0.4
1.0
2.2
0.4

0.4
1.2
4.2
0.5

12.5
51.0

Fat.

0.2

0.1
0.1

o:o5

0.1
0.6
1.0
0.05

2.2
20.0

Carbo-
hydrate.

4.2

0.9
2.2
5.1
2.3

0.9
5.9
6.2
2.4

30.0
123.0

194

GENERAL PLAN OF TREATMENT

167

TABLE X.

Carbohydrate Tolerance Test.
A Day's Diet with 100 Gm. Carbohydrate.

Food.

Breakfast.

Canned asparagus..

Beets

Celery

Clear soup

Coffee

Dinner.

Lettuce

Raw tomato

Carrots

Cabbage

Clear soup

Canned okra

Celery

Kaffee Hag

Supper.

Lettuce

Celery.

Turnips

Clear soup

Canned okra

Raw tomato

KaSee Hag

gm.

ISO

208

SO

100
203
218
172

90
SO

SO
100
230

90

S4

ISO
ISO

150

ISO

ISO

150

Gm

Calories.

Protein.

gm.

2.3
3.2
0.7

1.3

1.6

2.3
3.5

0.7
0.6

1.5
1.4
3.2

0.6
0.4

23.3
95.5

Fat.

Carbo-
hydrate.

gm.

0.2
0.2
0.05

0.4
0.8
0.8
0.6

0.1
0.05

0.2
0.1
0.4

0.1
0.2

4.3
45.6

gm.

4.2

20.0

1.5

3.3

7.9

20.0

10.0

3.2
1.5

1.7

3.0

20.0

3.2
2.1

101.6
416.6

557.7

168

CHAPTER n

TABLE XI.

Carbohydrate Tolerance Test.
A Day's Diet with 250 Gm. Carbohydrate.

Food.

Breakfast.

Orange

Canned peas

Carrots

Rice

Coffee

Clear soup

Dinner.

Grapefruit

Lettuce

Canned asparagus..

Potato

Canned lima beans.

Turnips

Kaffee Hag

Clear soup

Supper.

Apple

Lettuce

Raw tomato

Parsnips

Onions

Kaffee Hag

Clear soup

104

204

218

39

200
100
ISO
168
205
230

120
100
64
122
303

150
150

150
150

150
150

Gm

Calories .

Protein,

gm.

0.8

7.2
2.3
3.0

1.3
2.3
2.0
8.2
3.2

0.6i
1.3
0.5
2.0
5.1

Fat.

39.8
159.1

gm.

0.6
0.4
0.8
0.1

0.4
0.2
0.1
0.6
0.4

0.6
0.4
0.2
0.6
1.2

6.6
61.4

Carbo-
hydrate.

gm.

10.0
20.0
20.0
30.0

10.0
3.3
4.2
30.0
30.0
20.0

20.0

3.3

2.5

19.6

30.0

252.9
1025.0

1246

GENERAL PLAN OF TREATMENT

169

TABLE XII.
Exclusive Protein Diet, as Sometimes Used for Bringing Down Blood Sugar.

Food.

Breakfast.

Egg white

Celery T.C.*

Spinach "

Coffee

Clear soup

Bran biscuits (2)

Dinner.

Flounder

Sauerkraut T. C

Brussels sprouts T. C.

Bran biscuits (2)

Coffee.

Soup

Supper.

Roast chicken

CauHflowerT. C

Asparagus "

Bran biscuits (2)

Kaffee Hag

Soup

Gm

Calories.

gm.

162
200
100

216
200
200

78
200
100

150
ISO

150
150

150
150

Protein.

20.0

30.0

25. 0

75.0
307.0

Fat

0.3

1.2

3.4

4.9
45.0

352

' T. C. indicates thrice cooked.

170

CHAPTER n

TABLE Xni.

Example of a Low Maintetiance Diet for a Case of Extreme Severity; Body Weight

30 to 40 Kilograms.

Food.

Bieakfast.

Eggs

Bacon

Butter.

Celery T.C

Bran biscuits (2).. ,

Coffee

Clear soup

Dinner.

Flounder.

Butter

Lettuce

Raw tomato

Cauliflower T. C. .

Asparagus " . .

Bran biscuits (2)...

KaffeeHag

Clear soup

Sup per.

Eggs

Cream cheese

Butter.

Lettuce

Canned asparagus..

Spinach T.C

Cabbage "

Bran biscuits (2) . .

Kaffee Hag

Clear soup

Gm

Calories.

gm.

100

50

7

200

72

7

25

34

200

200

100

13

7

25

71

200

200

150
150

Protein.

150
150

150
150

14.9
5.0

10.0

0.4
0.2

14.9
3.3

0.4
1.0

50.1
205.0

Fat.

gm.

10.6

33.6

5.8

0.4
5.8
0.1
0.1

Carbo-
hydrate.

10.6
4.1
5.8
0.1

77.0
716.1

gm.

0.9

1.3

0.9
2.0

5.1
21.0

942

GENERAL PLAN OF TREATMENT

171

TABLE XIV.

Specimen Diet of a Child Aged 3 or 4 Years {Patient No. 73), with Extremely Severe
Diabetes; Weight 9 Kilograms.

Food.

Protein,

Fat.

Carbo-
hydrate,

7:30 a.m.

Egg

Milk

Butter.

Asparagus T. C...

Clear soup.

Bran biscuit (1)

11:00 a.m.

Egg.

Milk

Canned asparagus..

Butter.

Clear soup.

1:00 p.m.

Milk

Butter.

Raw tomato

Clear soup

Bran biscuit (1).. . .
3:00 p.m.

Milk

Clear soup

5:30 p.m.

Egg.

Milk

Butter.

Celery.

Bran biscuit (1)....

Clear soup

SO
25

7
75

50

25

107

6

50

6

60

25

50
25

7
75

100

100

100

100

100

Gm

Calories.

(m.

7.4
0.8

7.4
0.8
1.6

1.6
0.5

0.8

7.4
0.8

1.0

30.1
125.0

gm.

5.3
1.0
5.8

5.3
1.0
0.1
4.9

2.0
4.9
0.2

1.0

5.3
1.0

5.8

43.6
405.0

1.3

1.3
3.0

2.5
2.3

1.3

1.3

2.2

15.2
62.3

591

172

CHAPTER n

TABLE XV.

Example of a Maintenance Diet, Showing the Substitutions Indicated for Patients Who

Cannot Perform Calculations for Themselves.

Protein 90 gm. Carbohydrate 50 gm. Calories 2000.

Food.

1

i

V

1

Substitutes.

gm.

cc.

gm.

gm.

gm.

Breakfast.
Eggs

100
50
13

ISO

96

20
•25
150

295

100

19

100
SO
20
25
75
323
172
19

ISO
LSO

150
150

ISO
150

14.8
5.0

2.3

22.3

0.4
1.2

4.4
1.6
4.9

14.8
5.0

0.4
1.0
6.7
3.5
4.9

10.6

33.6

10.7

0.2

1.5

16.5
0.1
0.6

0.3
0.8
6.0

10.6

33.6

16.5

0.1

1.6
0.6
6.0

4.2

0.8
5.9

10.0
6.0

0.8

2.2

10.0

10.0

Bacon

Butter

Canned asparagus.
Bran biscuit (2)...
Coffee

Fresh asparagus 124 gm. (in place of canned).

Clear soup

Dinner.

Roast beef

Butter.

Roast chicken 69 gm.less butter 2 gm.

Flounder 160 gm.

Veal 79 gm.

Roast Lamb 113 gm. less butter IS gm.

(in

place of

roast

beef).

Radishes 25 gm. (in place of lettuce).

Raw tomato

Canned Brussels

sprouts

Cauliflower

Cream cheese

Bran biscuits (2) . .

Kaffee Hag

Clear soup

Supper.

Beets 61 gm. (in place of tomato).

Carrots 109 gm. (in place of Brussels sprouts).

Celery 200 gm. (in place of cauliflower).

Bacon

Butter

Lettuce

Celery

Dill pickle 82 gm. (in place of celery).

Spinach

String beans 107 gm. (in place of spinach).

Cabbage

Turnips 115 gm. (in place of cabbage).

Cream cheese

Bran biscuits (2)..

Kaffee Hag

Clear soup

Sauerkraut 228 gm. (in place of cabbage).

Gm

93.2
369.0

149.9
1394.1

50.0
205.0

Calories

1968

ClSRBiGHTDRATE

GENERAL PLAN OF TREATMENT 173

E. Food Tables.

The accompanying graphic charts illustrate a short method for
approximating food values, which can be made both more convenient
and more accurate if enlarged and used for wall charts. The abscissa
represent grams of foodstuffs; the ordinates show both grams and cal-
ories of carbohydrate, protein, and fat respectively. Thus, taking
the number 50 at the bottom of the carbohydrate chart, and follow-
ing the line up to where it cuts the line for sauerkraut, it is seen at a
glance that 50 gm. of sauerkraut contain 2 gm. or 8.2 calories of car-
bohydrate. Conversely, if it is desired to select food containing 5 gm.,
of carbohydrate, one may start at the number 5 on the left of the chart
and by following it across may see that this quantity is represented
in about 51 gm. of onions, about 67 gm. of blackberries, about 100
gm. of either grapefruit or milk, etc. The same method is used in
finding protein and fat values in the other charts.

The food values in Tables XVI to XIX are taken almost entirely
from the tables of Bryant and Atwater, Bulletin 28, Department of
Agriculture, Bureau of Experiment Stations, Washington, D. C. Simi-
lar tables, along with analyses of cooked foods, etc., are given in the
book on "Food Values," by Edwin A. Locke, Appleton and Company,
1914.

Abundant data for diabetic needs are contained in Joslin's text-
book. The list given in Chart 1 and Tables XVI to XIX is not
extensive, but yet contains nearly everything found necessary for
the diets in this hospital. Copies are supplied to patients for
reckoning their diets at home.

174

CHAPTER n

TABLE XVI.

Meat and Fish*

Edible portion.

Protein.

Fat.

Carbohy-
drate.

Meats.

fer cent

10.0
20.5
20.8
22.8
20.2
19.5
19.7
19.1
21.0

18.8
19.0
15.8
13.9
18.3
20.6
20.9
18.6

per cent

67.2

6.4

5.8

1.8

20.8

14.4

19.0

12.4

3.6

0.5
1.2
0.4
0.6
5.2
12.8
3.8
9.5

per cent
0

Beef sirloin verv lea,ii

0

" round " "

0

0

0

0

" loin . ...

0

Lamb

0

Veal

0

Fresh fish.

Sea bass

0

Blue fish

0

Cod, fresh

0

FlouiMier

0

Halibut

0

0

Shad roe

2.6

" whole :

0

*Uncooked values.

GElsTERAL PLAN OF TREATMENT

175

TABLE XVII.
Vegetables, in Order of Their Carbohydrate Content from Lowest to Highest.

Edible portion.

*Mushrooms (range 2 to 18 per cent) .

Cucumbers, fresh

Asparagus, canned

Celery, fresh

Spinach "

Asparagus "

Lettuce " !

Brussels sprouts, canned

Rhubarb, fresh

Tomatoes "

" canned

Brussels sprouts, fresh

Sauerkraut

Artichokes, canned.

Leeks

Eggplant, fresh

Pumpkin "

Cucumber pickles

Kohlrabi, fresh

Cabbage

Cauliflower

Radishes

Turnips

Carrots

Beans, string, fresh

Beets, fresh

Peas, green, canned

Onions, fresh

Squash "

Lima beans, canned

Com, green, fresh

Peas " "

Parsnip, fresh

Artichoke "

Potatoes "

Lima beans "

Protein.

Fat.

Carbohy-
drate.

per cent

per cent

per cent

(3.5)

(0.4)

(6.0)

0.8

0.2

2.5

l.S

0.1

2.8

1.4

0.1

3.0

2.1

0.5

3.1

1.8

0.2

3.3

1.3

0.4

3.3

1.5

0.1

3.4

0.6

0.7

3.6

0.8

0.4

3.9

1.2

0.2

4.0

4.7

1.1

4.3

1.5

0.8

4:A

0.8

0.2

5.0

1.2

0.5

5.8

1.2

0.3

5.1

1.0

0.1

5.2

0.5

0.5

5.4

2.0

0.1

5.5

2.1

0.4

5.8

1.6

0.8

6.0

1.4

0.1

6.6

1.4

0.2

8.7

1.4

0.4

9.2

2.2

0.4

9.4

1.6

0.1

9.6

3.6

0.2

9.8

1.7

0.4

9.9

1.6

0.6

10.4

4.0

0.3

14.0

2.8

1.1

14.1

4.4

0.5

16.1

1.7

0.6

16.1

2.6

0.2

16.7

2.1

0.1

18.0

7.1

0.7

22.0

* Wardall, (/. Am. Med. Assn., 1917, kix, 1859-1862) pointed out that the
carbohydrate of ordinary mushrooms is in some non-extractable form, and the
nitrogen according to Mendel's analyses is likewise in non-protein, non-utilizable
compounds. The figures in the above table are therefore placed in parentheses
to indicate their misleading nature. It would appear that ordinary mushrooms
may be reckoned as having no appreciable food value, and that they therefore
mav be a welcome feature of the diabetic diet.

176

CHAPTER II

TABLE XVin.

Fruits, In Order of Their Carbohydrate Content, from Lowest to Highest.

Edible portion.

Protein.

Fat.

Carbohy-
drate.

Grapefruit

per cent

0.3
1.0
0.9
0.6
0.7
0.4
0.8

0.5
1.0
1.0
1.1
0.6
0.5

per cent

0.1
0.1
0.2

0.1
0.3
0.6

0.7
1.0
1.3

0.8
0.5

per cent
5.0

Watermelon.

6.5

Strawberries

6.8

Blackberries

7.5

Muskmelon

9.3

Peaches

9.4

Pineapple

9.7

Orange

9.7

Lemon juice

9.8

Cranberries

10.1

Raspberries

12.6

Grapes

13.3

Apricots

13.4

Pears

14.2

Apples

16.6

TABLE XIX.
Dairy Products.

Edible portion.

Protein.

Fat.

Carbohy-
drate.

Eggs.

per cent
14.9

3.3
3.0
5.97
2.5

37.1
28.2
26.9
25.9
28.8
29.6
23.0
15.4
27.6
15.9
18.7
22.6

per cent

10.6

82.4
4.0
O.S
7.36

18.5

17.7
32.0
31.6
31.7
36.2
38.3
29.4
21.7
34.9
21.0
27.4
29.5

per cent

Butter

Whole milk

5 0

Buttermilk

4 8

Whiting's milk*

Cream, average

4 5

Cheese.

Dutch

Cheddar

Cheshire

Cream

American, pale

" red

Limburger

0 4

Boudon

0.7
1 ^

Swiss

Brie

1 4

Neufchatel

1 5

Roquefort

1.8

' D. Whiting and Sons, 570 Rutherford Avenue, Boston. Mass.

CHAPTER III.
Case Records.

Seventy-six cases have been selected for publication, for reasons
stated in Chapter VII. Graphic charts have been chosen as the
clearest and most compact means of presenting the large mass of
clinical and chemical data. With a little attention to the key shown
on all the charts, it is beheved that they will be found simple and
self-explanatory. The curves of ammonia, total acetone, and total
acidity of the urine have been plotted as cubic centimeters of deci-
normal solution, for the sake of chemical calculations and comparisons.
This plan will doubtless prove somewhat confusing to many clinicians,
but the tables and summaries in the case histories express the results
in grams. The written history of each case is supposed to be followed
in conjunction with the graphic chart, and reference from one to the
other will be necessary to make both plain.

Table I is a general summary of the entire series. The data mostly
tell their own story. Further details, of the age incidence, complica-
tions, results of treatment, etc., are shown in Chapter VII. The
etiologic relations are discussed in Chapter VIII.

CASE NO. 1,

Female, unmarried, age 28 yrs. American; no occupation. Admitted Feb.
24, 1914.

Family History. — Grandparents lived to healthy old age. Father living, aged
58, has arterial hjT)ertension, neuralgia, and tendency to melancholia. Mother
died at birth of this patient. An uncle died of tuberculosis. One fuU brother of
patient died at 16 of appendicitis. One half-sister aged 22 has nephritis, conse-
quent upon scarlatina.

Past History. — No childhood diseases except measles and one dysenteric attack.
Normal menstruation began at 13. Patient graduated from university at 20.
She has had a nervous, overactive life with late hours and irregular eating. Was
considered remarkable among her family and friends for the amount of candy
and sweets she consumed. Normal weight 115 to 120 pounds. July, 1912, pa-
tient's fianc6 died of accidental poisoning. Patient became melancholic and kept

177

178 CHAPTER in

more to herself, while eating still more candy than usual. She and her parents
were inclined to attribute onset of diabetes to grief.

Present Illness.— In Jan., 1913, abnormal thirst was first noted. In Mar.,
pruritus vulvae. In May, menstruation stopped and remained absent. Hair
fell out and is still thin. July, 1913, diagnosis of diabetes was made and routine
diet prescribed, which was taken in huge quantities owing to polyphagia. Symp-
toms persisted and increased till Jan. 4, 1914, when she began treatment at a
well known diabetic sanitarium. Qualitative and quantitative restriction of the
diet, oat cures, vegetable days, etc., failed to clear up the condition. She was
then transferred to this hospital, and arrived tired but not dangerously exhausted
after a journey of 32 hours.

Physical Examination.— Height 165.6 cm. Weight 40.1 kg. Marked emacia-
tion, face flushed and slightly pufiEy, drowsy and slightly alcoholic expression.
No enlargement of tonsils or lymph glands. Blood pressure 103 systolic, 80 dias-
tolic. Examination otherwise negative.

Treatment: — This was the first patient for the proposed treatment, and she was
qloser to coma than was desired for a first trial. Accordingly the attempt was
made to be conservative. She was put to bed and a light supper ordered of two
eggs, a slice of toast, and a cup of milk-cocoa. Breakfast the next morning in-
cluded oatmeal; the rest of the diet was light and included vegetables and potato
in limited quantities. Notice should be taken that the blank food space in the
graphic chart for Feb. 24 to 25 does not represent fasting, but exact reckoning
of the diet was impossible because cooking and other arrangements were not in
readiness. At the same time liquids were forced to 6 or 7 liters per day, and alkali
was given as stated under acidosis below. As coma was imminent, there was no
choice but to take the chance of beginning the proposed treatment. Therefore
Feb. 27 was a vegetable day with 45 gm. carbohydrate and 530 calories. Feb. 28
was a fast-day with nothing but 200 calories of whisky. Marked improvement was
evident in the urine, which became alkaline, but there was a large bicarbonate
edema as illustrated by the weight curve, and weakness and drowsiness con-
tinued. Then, in order to guard against any supposed dangers of fasting, 20 gm.
oatmeal were permitted on Mar. 1, increased to 52.5 gm. on Mar. 2. By this
time glycosuria and coma symptoms were entirely cleared up, and alkali was di-
minished. On Mar. 3 the diet consisted of soy beans and green vegetables. On
Mar. 4 the diet was greatly reduced, consisting only of 90 gm. banana, 20 gm. oat-
meal, 10 gm. potato, and 10 gm. cream. The patient was extremely weak, there-
fore the attempt was made to build her up by a routine diabetic diet, in the hope
that she might be strengthened for later undernutrition treatment. No gain of
weight or strength was achieved, but glycosuria returned and the persisting acido-
sis was greatly increased, as shown in the graphic record. It was again reduced
by undernutrition, and brought to a minimum by a fast-day on Mar. 23. A
carbohydrate period was then instituted to clear up the tendency to acidosis if
possible, and the opportunity was taken to compare the assimilation of oatmeal

CASE RECORDS 179

and pure starch. On Mar. 24, 40 gm. Kahlbaum's soluble starch were the only
nourishment given, and 80 gm. on each of the succeeding days, in ten doses of 8
gm. each. On Mar. 29 a change was made to oatmeal, reducing the quantity of
carbohydrate slightly as an allowance for the oat protein. Nevertheless a gly-
cosuria of 1.39 gm. appeared on Mar. 31, proving the absence of any superiority
of assimilation of the oatmeal over the soluble starch. The resulting traces of
glycosuria were cleared up by a fast -day on Apr. 1 . Acidosis now being entirely
absent, another attempt was made to overcome the persistent weakness by as
high a diet as possible without glycosuria. Though the attempt was made to
balance protein, fat, and carbohydrate to this end, the graphic record shows that
acidosis returned promptly, and glycosuria resulted on Apr. 12. This was cleared
up by a fast-day on Apr. 14. The attempt was then made to build up strength by
still higher diet and to diminish acidosis by increasing carbohydrate, even at the
cost of glycosuria, with the idea that glycosuria could later be checked by brief
fasting. Acidosis was not controlled, and weight and strength were not gained,
and on Apr. 25 this attempt was abandoned. From this date to May 1, pure pro-
teici-fat diet was attempted, but both glycosuria and acidosis were present. At
this time a more rigid program of undernutrition was begun. It will be seen
chat the calories during May averaged less than 1000 daily, a maximum of car-
bohydrate was introduced, and frequent fast-days were employed. The weight
diminished very slightly. The complaints of weakness were about the same.
Most of this period from May 1 to the end of July was vegetarian, chiefly nuts
and green vegetables, of which the patient was fond. On June 30 an enormous fat
intake was permitted experimentally, as mentioned under acidosis. No special
virtue of the vegetarian regime was perceptible. Glycosuria and acidosis were
practically absent during the undernutrition of the month of May; both returned
with the higher caloric diet of June and July. This period was terminated be-
cause of the increasing weakness of the patient, due particularly to the low pro-
tein. In the period July 10 to 14 a test was made with raw pancreas feeding as
described in Chapter IV.

Most of the month of Aug. was occupied with pure protein-fat diet of between
1000 and 1100 calories, and about 30 gm. protein. The patient was relieved
of the fast-days, of which she had been complaining bitterly. Glycosuria was
mostly absent, but acidosis was persistent. In Sept. the calories were increased,
partly by use of alcohol, and a few fast-days mitigated by vegetables or alcohol
were employed. Weight and strength were not thereby improved, and both
glycosuria and acidosis were troublesome. Oct. was a period of marked undernu-
trition, the calories being mostly about 900 daily, carbohydrate-free, except for
two tests in which respectively 60 and 58. 8 gm. carbohydrate resulted in glycosuria,
when added to this caloric intake. In Nov. and Dec. the carbohydrate-free diet
was pushed to the upper limit of tolerance, so that traces of glycosuria and keto-
nuria kept recurring and were checked by occasional fast-days. The attempt
thus to build up weight and strength failed as usual. The patient was dismissed

180 CHAPTER m

on Dec. 20 with instructions to continue diet as during Dec. and to take a fast-
day once each week.

Acidosis. — ^The excretion of acetone bodies in the first few days was evidently
very high, but the analyses were lost. Notwithstanding the alkali dosage, the
urine was strongly acid, and the ammonia nitrogen was 1.7 gm. on Feb. 25 and
1.93 gm. on Feb. 26. Each day the patient took 2.4 gm. potassium citrate, small
quantities of light magnesia, and calcium carbonate in quantities equal to the so-
diurii bicarbonate. It was thus hoped to provide a balance of salts, and perhaps
also to neutralize some acid with a non-irritating substance such as chalk. The
sodium bicarbonate dosage was as follows: Feb. 25, 20 gm.; Feb. 26, 32 gm.; Feb.
27, 72 gm.; Feb. 28, 48 gm.; Mar. 1 to 7, 40 gm. daily; Mar. 8 to 20, 20 gm. daily.
All alkali was stopped at this time. No efiect upon the carbohydrate tolerance
was evident.

As mentioned, acidosis was brought under control by the initial undernutri-
tion period. With the high diets (Mar. 10 to 15) it returned very markedly, the
ammonia nitrogen rising slightly above 1 gm. notwithstanding the alkali dosage,
and the ketonuria reaching 28.7 gm. (as j8-oxybutyric) on Mar. 15. With a single
fast-day (Mar. 16) the ammonia nitrogen fell to 0.63 gm. and the acetone bodies
to 9.57 gm. With reduced diet the acidosis diminished further, and, was entirely
abolished by the carbohydrate period, Mar. 24 to 31, the ammonia and acetone
figures falling to normal, and the ferric chloride reaction turning entirely negative.
MildCT acidosis returned with the beginning of mixed diet after Apr. 2, and it was
proved that carbohydrate, even to the point of causing glycosuria, could not keep
acidosis absent. Especially in the period Apr. 19 to 24 the carbohydrate was
gradually increased to 90 gm., with a total diet as high as 2800 calories (over 75
calories per kg. on 37 kg. weight). The highest glycosuria resulting was 7.26
gm. on Apr. 24. This program was adopted on the principle frequently stated
in the literature, that 90 gm. carbohydrate intake is worth a glycosuria of 7 gm.
The attempt was to build up weight and strength with the high diet, while keep-
ing acidosis in check by a favorable carbohydrate balance. Acidosis, however,
remained present as stated, and the peculiar weakness and malaise characteristic
of severely diabetic patients with even moderate acidosis persisted likewise.
Carbohydrate had to be discontinued in order to check the steady increase of gly-
cosuria. Thus the diets of Apr. 29 to 30 consisted of 61 gm. protein and 200 gm.
fat. Both protein and fat were then diminished, until on May 1 the diet was 53
gm. protein and 177 gm. fat. This would correspond to an orthodox diabetic diet
of about 1.5 gm. protein and 37 calories per kg. Nevertheless slight glycosuria
and heavy ferric chloride reactions persisted, and the ammonia nitrogen by May
1 was up to 1.2 gm. May 2 was a fast-day with 34 gm. butter, this quantity of
fat being abnost negligible for either good or ill. The glycosuria ceased before the
close of the 24 hours, the ferric chloride reaction diminished to a trace, and the
ammonia nitrogen fell to 0.6 gm. Thus 1 day of undernutrition accomplished
' what had been impossible on full diets either rich or poor in carbohydrate.

CASE RECORDS

181

For the next 3 months a vegetarian r6gime was tried, as described under "weight
and nutrition" below. Because of the low protein and fat, a relatively high car-
bohydrate tolerance was exhibited, which was also assisted by the very frequent
fast-days. In this way both glycosuria and acidosis were almost continuously
absent for a month. The hope of a gain in tolerance was disappointed, however,
as demonstrated by the prompt return of both glycosuria and ketonuria when a
moderate increase of diet was attempted in June and July.

On June 30 an enormous fat intake was allowed experimentally for a single
day, followed by a series of lower diets, as shown in Table II.

TABLE n.

Diet.

Urine.

Date.

Protein.

Fat.

Carbo-
hydrate.

Calories.

Volume.

Sugar.

Total
nitrogen.

NH.-N

Acetone

bodies (as

l8-oxy-

butyric).

IHM

gm-

gm.

im.

cc.

gm.

gm.

gm.

gm.

June 27

43.1

104.7

87.0

1403

2320

+

4.02

0.35

0.78

" 28

40.0

104.8

85.9

1415

3188

3.31

4.38

0.41

1.66

" 29

0.5

123.9

3.4

1270*

1858

0

2.17

0.35

0.62

" 30

83.6

448.6

72.4

4456

2128

+

4.55

0.92

4.67

July 1

74.7

292.8

51.0

2707

2629

4.12

11.38

1.34

8.57

" 2

57.4

185.7

64.0

2013

1422

7.11

4.54

0.91

3.21

« 3

57.6

202.0

68.3

2107

1852

14.63

6.22

2.00

5.64

" 4

41.0

112.0

39.0

1295

1411

4.06

6.28

1.50

. 2.73

" S

0.2

0.2

1.8

290t

1506

0

4.14

0.80

0.47

" 6

36.3

109.8

72.6

1315

1528

0

6.17

0.38

1.11

" 7

55.1

101.2

68.2

1420

1630

0

7.02

0.43

0.48

* Butter 150 gm., strawberties 50 gm., alcohol 25 gm.
t Alcohol 40 gm.

The relation between combustion of food fat and body fat is here illustrated.
The huge ration of June 30 did not produce any explosive increase of acidosis. The
acetone bodies showed a rise on the same day, but a more marked one the follow-
ing day, while the ammonia nitrogen did not reach its summit until July 3. It is
evident that what happened was not the conversion of any large proportion of the
fat on June 30 into acetone bodies, but rather an injury of fat assimilation pro-
duced by this excess and continued by reason of the fat rations (lower but still
excessive) of July 1 to 3. On the fast-day of July 5, storage or depot fat was
necessarily burned, yet the ammonia nitrogen was approximately the same as On
June 30. On July 6, with a limited fat intake, the effect of carbohydrate was
evident in producing a lower ammonia nitrogen excretion than on the fast-day.
The entire observation is against the idea of a difference between food fat and

182 CHAPTER in

body fat in combustion, and indicates rather an overtaxing of fat metabolism by
excessive intake and improvement of assimilation by relief from the strain.

On the carbohydrate-free diet beginning in Aug., strong ferric chloride reactions
and unduly high ammonia excretion were the rule. Temporary control of both
glycosuria and acidosis was achieved with the low diets (about 900 calories) in early
Oct. Thereafter it will be noted that the ferric chloride reactions were some-
times negative and never more than slight, even on carbohydrate-free diet, the gen-
eral diabetic condition being now under better control. The continuance of slight
acidosis, however, throughout so much of the period of treatment represents one
of the serious mistakes in the management of this case.

Weight and Nutrition. — ^Weight at admission 40.1 kg., at discharge 35.2 kg.;
i.e., a loss of 4.9 kg. The initial gain in weight, up to 43.5 kg. on Feb. 28, repre-
sented a marked bicarbonate edema, simultaneous with the turning alkahne of
the urine. Slighter edema was present on certain occasions later, notably Aug.
15 and Nov. 7, being due apparently to sodium chloride and removed by diminish-
ing the salt intake.

On Mar. 21 the large fluid intake began to be restricted. The patient had
been accustomed to large quantities of water for some months past and com-
plained of thirst when the allowance was diminished by order; within a few days
this complaint disappeared and the thirst remained normal thereafter.

Vegetarian diet was tried for a period of nearly 3 months, chiefly because of
the claims in some quarters concerning differences in the glycosuric effect of
different proteins, and the bare possibility that meat protein might at least
stimulate a greater flow of gastric juice and correspondingly of pancreatic juice,
and thus perhaps depress the internal function of the pancreas by stimulating
its external function. Undernutrition was employed at the same time to create
the most favorable conditions, and acidosis was kept absent by such quantities
of carbohydrate as seemed within the tolerance. Butter was regularly allowed,
eggs rather frequently, and a Uttle bacon and bacon fat sometimes, but for much
of the time the ration was vegetarian in the strictest sense, composed entirely of
vegetables, fruits, nuts, soy beans, and occasional gluten preparations. There
was no gain of tolerance, and no advantages of a vegetarian diet or evidence of
specific differences between proteins were observed.

Neither food nor feces was analyzed. The former was calculated as usual
from the Atwater-Benedict tables. On this basis the following reckoning can be
made for the period from Mar. 16 to Nov. 30, for which the records of both food
and urine are complete. Also, the total period of 260 days is divisible into two
nearly equal portions, namely, 136 days up to July 31, during which the diet was
largely and sometimes wholly vegetarian and contained considerable carbo-
hydrate, and 124 days after July 31, in which the protein was of animal origin
and the diet was almost continuously carbohydrate-free. The results for the
various periods may be compared as shown in Table III.

CASE RECORDS

183

^

ej .

g (^ 10 irj

3 !3

S CN ■^ll 0

o5

fe^ T-J 0\ ro

.■§ o

a g

gm.
2.63
0.21
2.40

H

T-4 0 ^

1 (M S .rt

_g

i^ 0\ 00

■3 fl 2

0\ O; o\

■SS-S

S 0;' CO d

Hss

5 0 10 ^H

^ o\ t>»

■3

i-H

Total
nitrogen

in diet
per day
per kg.

0. c^ vo

E d d d

2* fl-.. t^

. ■* ^ lO

g CN >0 0

"^ t^ 00 \o

A .S

nitr
n in
prote
5.25).

0 CN ■*
S IN 0\' «

" S^.i.

Si cio in CN

00 o_ 00

0 aj '

H ■■V

w ^

M

Average
protein
per day
per kg.

sm.
1.23
1.44
1.02

a

!•§&■

. <N rf OS

tH^TJ

E "3 ro t^'

f^

I^R

h3

Th 10 re

g

2

•<l; 0 f)

H

3'a*.-

.000

o'S.S

S « tN rC

H^-o

^ *^ ^., ^

g

^" vo" i^

a

-'

Average
calories
per kg.

per day.

ce ro re

CO PO re

t|l

ro ■* T-i

^ 0 !N

C>l^ CN_ CN

.5

<N SO vo

si^"

*^ to w

Ce_ (N VH

,|,

•W as 0" ■

^ -"^ so
CO « ^

en

>,

tS

-a

^ 1

0 "5 "C

so 0 OJ

IN -a a

^ ^=«

• 2 n •— 4

tal per
nimal'
egetab

£<>

H

::

;;

1

184 CHAPTER ni

The patient lost 5 kg. weight in 9 months. If it be assumed that 90 per cent
of a weight change is ascribable to fat, in this instance the loss of nitrogenous
"tissue" would not exceed 500 gm. Using Voit's figure of 3.4 per cent N, the
possible loss of body nitrogen would then be 17 gm. If it be urged that in an
emaciated person the wasting of "tissue" in proportion to fat is higher, the
above comparison of intake and output shows that the patient must have been
nearly in equilibrium. At worst, the nitrogen deficit must have been small, and
it may be assumed that the diet fulfilled the purpose of protecting body protein
from any extreme loss while maintaining prolonged undernutrition.

Two deductions seem justified. (1) Digestion and absorption of protein
were, as would be expected, distinctly better during the "animal" period, but the
utilization of vegetable proteins, including the times when the diet was exclu-
sively vegetable, was reasonably satisfactory. (2) Though the nitrogen intake
was lower in the "vegetable" period, it must be called low also in the "animal"
period, and it is evident that there is no serious obstacle to maintaining equilib-
rium on strict carbohydrate-free diet with a low protein ration. It is to be borne
in mind that the energy intake is a question not of food ingested but of food ab-
sorbed. If it be permissible to assume that the same proportion of total calories
as of nitrogen was lost in the feces, viz. 11.29 per cent, subtraction of this num-
ber from the 33 calories ingested daily would leave an average of between 29 and
30 calories absorbed daily per kg. of body weight. Accordingly, it would appear
that this patient lived for 260 days on an average of 0.173 gm. N and 30 calories
per kg. Work and exposure to cold were both far less than in ordinary individuals.
On the other hand, the rather tall, very emaciated figure presented a dispropor-
tionate surface. Losses in sugar and acetone bodies were sKght. On the whole,
the figures obtained correspond satisfactorily to the known laws of metabolism
in normal persons.

Subsequent History. — On Jan. 14, 1915, the patient reported by telephone that
she was feeling well and had cleared up occasional traces of glycosuria by fast-
days. On Jan. 20 she reported increasing difficulty in remaining sugar-free, and
was instructed to return to the hospital if difficulty continued. Nothing more
was heard until Apr. 1, when a letter stated that she had returned to her home
in Indiana. On Apr. 26 a response to a letter of inquiry showed that the cause of
her silence and removal was her adoption of Christian Science. Occasional
later reports showed that she was eating everything at will, including much
candy,, and gradually losing strength. Death occurred from simple weakness
the first of Oct. 1915, the terminal collapse being brought on by taking a dose of
Epsom salts.

Remarks. — The patient, when received, was undoubtedly close to coma. She
appeared then as having diabetes of extreme severity. The results obtained
seemed highly favorable. In the light of later experience this treatment was
very bad.

Part of the fault lay with the patient, who had always eaten injudiciously

CASE RECORDS 185

and was the most unruly of the entire series for dietary control. The high
diets, the persistence of glycosuria and ketonuria through considerable periods,
and the changes in program from time to time were in some measure forced by the
necessity of appeasing the patient's demands and meeting her psychic needs.
She insisted not only upon nourishment but also taste and satiety, and slight pri-
vations brought on hysterical tears and melancholy which seemed serious as a
possible influence upon the diabetes, though, as a matter of fact, no particular
influence of psychic upsets upon the food tolerance was observed. She was given
unusual leeway as being the first patient.

The cause of the final disaster was also instructive. It is noteworthy that al-
though a very careful limitation of diet both quantitatively and qualitatively
had resulted in threatened coma at the time of admission, subsequently on abso-
lutely unrestricted diet no symptoms of acidosis were described, evidently be-
cause the patient lived so largely on carbohydrate, and the polyiiria aided in the
elimination of acetone bodies. Although the patient was young and the kind
that typically dies in coma, death occurred from simple wasting and asthenia.

The chief difficulty consisted in inexperience with the treatment. The cautious
manner of beginning treatment, and the partial, irregular, and inadequate charac-
ter of the measures employed belonged to this stage of uncertainty and orienta-
tion. It showed the viciousness of some of the accepted methods in the man-
agement of diabetes. The same patient admitted at a later time could have been
treated far better; and the case, though severe, was mild in comparison with
some of the later ones. A bold initial fast, followed by testing of the tolerance
for different classes of food and arrangement of a diet accordingly, would have
brought far quicker and better results.

The actual accomplishment was that the patient was kept alive in the hospital
from Feb. 24 to Dec. 20, with a loss of 5 kg. (one-eighth of her weight at en-
trance), and about a corresponding diminution of strength. Glycosuria and
acidosis were kept entirely absent at certain times, and were controlled within
small quantities at all times. Actual food tolerance was slightly less at the end
than in the earlier part of treatment, and the progress was slowly but distinctly
downward. The bungling and inadequate treatment furnished abundant reason
for this slight downward progress in 10 months, and no "spontaneous" cause
need be assumed. Methods and results of this sort have been common with a
large proportion of practitioners who have undertaken to apply the fasting
therapy. The record of this patient stands as a useful example of how a case
should not be treated.

CASE NO. 2.

Female, unmarried, age 17 yrs. Italian, sewing machine operator. Ad-
mitted Apr. 13, 1914.

Family History. — Grandparents healthy as far as known. Father a day laborer
and short of stature; weight about 200 pounds. Mother short, normal figure,

CASE RECORDS 187

was agreeable to this Italian patient. In other words, the fast was not broken
(as usual) by carbohydrate alone, but fat was introduced to make a total of 2000
calories. Also on the following days, diets low and relatively high in fat were
comparfed, and on Apr. 30 a day of 100 gm. olive oil was given instead of a regu-
lar fast-day, according to the practice of some authorities. The results are dis-
cussed elsewhere (Chapter VI). They illustrate the harmfulness of attempts to
use fat in this manner. In the first few days of May a rather low diet was given,
with absence of glycosuria. The succeeding period represents a low calory diet,
with as much carbohydrate as possible and frequently repeated fast-days for the
purpose of overcoming the persistent ferric chloride reaction. On June 11 an
enormous fat diet was given (137 gm. protein, 34 gm. carbohydrate, 6672 calories
= 167 calories per kg.) . A slight rise in the ammonia followed, but the patient's
appetite was spoiled so she could take only a low diet for several days. On June
17 a less extreme fat diet was begun, which nevertheless represented not far from
100 calories per kg. of body weight. The results are discussed in Chapter VI.
The onset of glycosuria and the marked rise of acidosis are the striking features.
July S was a fast-day with alcohol. Thereafter a low diet was given, relatively
rich in carbohydrate. Under this program both glycosuria and acidosis cleared
up and were kept absent.

The patient was discharged Aug. 14, symptom-free and feeling well and strong.
The hospital stay was uneventful except for occasional headaches for which no
cause was found.

Acidosis. — Although there were no signs of coma, the analyses in the first few
days indicated that trouble would have resulted before long on the restricted
diet. On Apr. 14 to IS no alkali was given, and the urine contained 2.4 to 2.7
gm. ammonia nitrogen and 4.2 to 7.0 gm. acetone bodies (as |S-oxybutyric) .
Apr. 16 to 20, 20 gm. sodium bicarbonate were given daily, and 10 gm. on Apr. 21,
after which alkali was stopped. The rise of ketonuria, up to 12.1 gm. /3-oxybutyric
acid on Apr. 18, was to be expected, but at the same time the ammonia, instead of
falling, remained little changed, and actually rose to 3.1 gm. ammonia nitrogen
on Apr. 18. With diminished fat and increased carbohydrate intake on Apr. 19
there was a drop in both ammonia and total nitrogen, but the steepest fall of the
ammonia occurred on fasting. Thereafter the three principal peaks of the
ammonia curve (Apr. 23, May 2, and June 19 to July 3) are clearly associated
with the fat content of the diet. It is evident from the graphic chart that acidosis
was not checked by hberal quantities of carbohydrate and protein, nor by a fav-
orable carbohydrate balance, but on the contrary rose and fell according to the
ingestion of fat. For about the last month in the hospital acidosis was entirely
absent on a diet moderate in protein, relatively abundant in carbohydrate, and
low in fat.

Weight and Nutrition. — Weight at admission 42.6 kg., at discharge 40 kg.;
i,e., a loss of 2.6 kg. The variations and excesses in diet were experimental.
The diet at discharge was approximately 56 gm. protein, 120 gm. carbohydrate.

188 CHAPTER in

and 1400 calories (1.4 gm. protein and 35 calories per kg., reduced slightly by
occasional fast-days). The patient's figure and strength at discharge appeared
normal. The diet was planned as one on which she could work. She was in-
structed not to gain weight, and it was proposed to give her instructions there-
after chiefly on the basis of her body weight.

Remarks. — ^Aside from the intentional experimental variations, the treatment
was fairly efficient and the result good. The reduction in weight and the arrange-
ment of the final diet, restricted in total calories, adequate "in protein and rather
liberal in carbohydrate, was about what was needed for a relatively mild case,
such as this one by this time had proved itself to be. By comparison of the
diets of Apr. 14, IS, 18, and 19 with those of Aug. 9 and 11, it will be seen that
the calories are about the same, while the carbohydrate, counting also that deriva-
ble from proteia, is higher in the latter period. Along with this, the sharp
contrast as respects glycosuria and ketonuria shows a decided upward progress
in this 17 year old girl during these 4 months.

Subseqtient History. — ^After discharge on Aug. 14, the patient followed diet and
remained sugar-free for about a month at home. Owing to poverty it was almost
impossible for her to obtain the necessary food, and she gradually began to take
the diet of the rest of the family. Sugar reappeared, followed by other symptoms.
She was readmitted Nov. 30, 1914, complaining of polydipsia, polsoiria, and for the
last few days loss of appetite and drowsiness.

Second Admission. — A 4 day fast was instituted, glycosuria ceasing on the 3rd
day. On Dec. 4, green vegetables containing 20.5 gm. carbohydrate were taken
without glycosuria. Another fast-day was then given as a therapeutic measure,
and a mixed diet of eggs, butter, steak, and vegetables gradually begun. Slight
glycosuria appeared within a few days. Beginning Dec. 16, the diet was almost
constantly carbohydrate-free and unduly high in calories. Ketonuria was pres-
ent most of the time up to July 24. Then, after a fast-day, a carbohydrate test
was given in the form of green vegetables as usual. Beginning with 10 gm. car-
bohydrate on July 26, an increase of 10 gm. daily was made. Aug. 4, on 100 gm.
carbohydrate, she showed a trace of sugar, which disappeared the next day when
the same carbohydrate was given. The true hmit was reached on Aug. 8 with
130 gm. carbohydrate. Accordingly, 120 gm., which had been tolerated the pre-
vious day, were accepted as her tolerance. The acidosis was thus cleared up
(compare with increase of acidosis when fat was given in Apr., 1914). It returned
in smaU amount on the subsequent carbohydrate-free diet, then diminished, so
that after Sept. 7 it was absent. Another carbohydrate tolerance test was madfe
beginning Oct. 11, and the limit was found to be practically the same as in Aug.
Small quantities of carbohydrate were added to the diet in Nov., but discon-
tinued on account of glycosuria. Beginning Dec. 13, a third carbohydrate tol-
erance test showed imchanged assunilation, and cleared up the sUght ketonuria
which had again developed on protein-fat diet. Carbohydrate was again included
in a diet somewhat lower in calories, but was discontinued on account of persistent

CASE RECORDS 189

slight glycosuria. Strenuous exercise was a feature of the treatment during this
period in the hospital. The observations are discussed in Chapter V. The
patient was discharged Feb. 2, appearing healthy and well nourished and feeling
strong and capable of hard work.

Acidosis. — The ammonia excretion was constantly higher than that of normal
persons; perhaps not higher than some normal persons would show on the same
diet. No determinations were made during the carbohydrate tests, when lower
values might have been found. A fall of the ammom"a on fast-days and a rise on
carbohydrate-free diet is shown by portions of the curve in Apr., May, and June;
this is doubtless due in part to corresponding variations in total nitrogen excre-
tion, but also illustrates the difference between fasting and protein-fat diet.
Beginning Dec. S, it is evident that a fast-day, followed by a reduction of fat in
the diet while keeping protein the same, resulted in a drop in ammonia excre-
tion. The carbon dioxide-combining power of the plasma remained in the
neighborhood of normal without alkali dosage, but nevertheless showed a ten-
dency to sink somewhat below the low normal limit. This was one of the patients
who showed a fall in blood bicarbonate on fasting, as seen particularly after the
fast-days of May 1 and Sept. 12. Certain other fluctuations in this curve are dis-
cussed in Chapter V in connection with exercise.

Blood Sugar. — This was mostly about 0.2 per cent. A rise is seen at the close
of the carbohydrate tolerance test in Oct. Analyses were not made during the
other carbohydrate tests. The normal values from Apr. 30 to May 11, and on
Sept. 22 and 23, showed that a reduction was possible by suitable low calory diet,
and the failure to insist upon such a level was one of the faults of the treatment.

Weight and Nutrition. — In general the lowest diets are those of Aug. and Oct.
and the dismissal diet about the 1st of Feb. These amounted to 1300 to 1500
calories, which for a body weight of 40 kg. would equal 35 calories or more per
kg. At other times this diet was increased by fat to as much as 3500 calories,
or some 60 calories per kg. Two modifying features come into account. One
is the number of fast-days, which serve to diminish the average intake some-
what below this figure. Second, the patient was kept most of the time on very
heavy exercise, so that the caloric requirement was increased. The patient en-
tered weighing 45.6 kg.; namely, a gain of some 5 kg. since her former discharge,
with a corresponding loss of tolerance. She was dismissed weighing 39 kg.;
i.e., with a loss of 6.6 kg. in 14 months in the hospital. To this extent the treat-
ment was one of undernutrition.

Remarks. — It was above noted that during 4 months in hospital, at the first
admission, progress was upward. The patient was at home about 3i months and
broke diet in the latter portion of this period. The downward progress is plainly
evident. After her second admission she frequently showed sugar on carbohy-
drate-free diet. Also her limit of tolerance for carbohydrate alone, in the green
vegetable tests of Aug., Oct., and Dec, 1915, was almost exactly the quantity
which could be included in her regular mixed diet in Aug., 1914, without any

190 CHAPTER III

appearance of glycosuria. It is thus clearly confirmed that a marked and last-
ing injury of assimilation can be produced by a few months of unregulated diet.
On the other hand, the former carbohydrate tolerance tests of Aug., Oct., and
Dec, 1915, covered a period of S months, and conclusively proved the absence of
any perceptible downward progress during that time. Also the weight remained
essentially the same, so that no disturbing factor was thus introduced. Moreover,
comparison of the tolerance at the beginning and end of the second hospital
period shows that glycosuria appeared on Dec. 14, 1914, on a diet of 60 gm. pro-
tein, 42 gm. carbohydrate, and 981 calories. If all these earlier occurrences of
slight glycosuria be ignored, it is still evident that on repeated occasions in Jan.,
Feb., and thereafter, glycosuria was present on carbohydrate-free diets of some
1700 calories. In contrast to this, it is seen that from Dec. 27, 1915, to Jan. 1,
1916, a diet of 1760 calories with 10 to 30 gm. carbohydrate was tolerated without
glycosuria, and the protein in this diet was fully as high as in the above men-
tioned carbohydrate-free periods. Glycosuria appeared only on Jan. 6, toward
the close of another week on the 30 gm. carbohydrate allowance. It was thus
present on Jan. 11, but cleared up on withdrawing carbohydrate from the diet.
A slight gain in food tolerance is thus evident during these 14 months in hospital,
and this upward tendency is the more remarkable in view of the improper treat-
ment, with its long periods of overfeeding and almost continuous marked hyper-
glycemia. The essential criticism of the treatment in this period is that by
pernicious protein-fat overfeeding (up to 60 calories per kg.) it held back the ten-
dency to improvement, and ultimately sacrificed 6| kg. weight for only the slight
gain of assimilation above mentioned. An excellent physical condition was main-
tained throughout, and the patient was discharged seemingly in splendid health.
The failure of the plan of feeding for immediate weight and strength is well dem-
onstrated by this prolonged trial. The transitory well-being is too dearly bought
at the price indicated by the laboratory findings. Proper management would
have imposed a rigid low diet from the outset and insisted upon continuously
normal urine and blood. A sharper initial fall of weight would have resulted.
A small quantity of carbohydrate could have been included in such a low calory
diet. Under such a program there is little doubt that the patient could have been
discharged in fully as good physical condition and on fully as high a total diet as
was actually the case; and the diet could have been balanced properly with car-
bohydrate, and the entire condition from the standpoint of the diabetes would
have been far more favorable.

Subsequent History. — After discharge on Feb. 2, 1916, diet was followed until
Mar. 8, when the patient began to take two slices of bread daily in addition to the
weighed diet, because of a strong craving for carbohydrate. Sugar had been ab-
sent before, but then reappeared and continued. She was doing 5 hours work
on the sewing machine at home and 2 hours housework daily, and in addition
walked two miles two or three times a week. A fast-day was taken once a week
up to the 1st of Mar.

CASE RECORDS 191

Third Admission. — Mar. 20, 1916. Weight 39.4 kg. Nutrition and strength
still appeared very good. Fasting was imposed Mar. 21 to 23 inclusive, then low
protein-fat diet, gradually increasing from 1000 to 1200 up to 1800 calories, with
protein ranging from 40 or 50 up to 60 or 70 gm. daily. The patient was again
discharged on July 12 at her own request, still appearing in excellent condition.
Headaches had been somewhat relieved after prescription of glasses by an
oculist.

Acidosis. — It is of interest that heavy acidosis was brought on by the addition
of two slices of bread to the weighed diet on which both glycosuria and acidosis
had been absent. Fasting was begun on the day following admission (Mar. 21).
The patient was depressed, dizzy, and significantly unwell. The finding of 33.4
per cent plasma bicarbonate showed the reason. Sodium bicarbonate was then
given in 3 doses of 10 gm. each. Within half an hour after the first dose the clini
cal effect was striking. The headache, dizziness, depression, and malaise van-
ished, and were replaced by comfort and cheerfulness. It is possible that fasting
alone would have been badly borne, as the tendency to a fall in blood alkalinity
on fasting was previously noted in this patient. No more alkali was given. The
CO2 capacity was found normal on the day after the bicarbonate dosage, but fell
to 46 per cent on the succeeding day (Mar. 23). On this day also glycosuria
ceased. Mar. 24 to 27, a trial was made of carbohydrate-free diet, which fre-
quently relieves fasting acidosis. On Mar. 24 nothing but 21 gm. protein was
fed, the diet being coffee, soup, and veal. The blood bicarbonate rose a trifle.
On Mar. 25 the diet contained 40 gm. protein and 800 calories. Thereafter pro-
tein was increased and fat diminished, so that on Mar. 27 the diet was 70 gm.
protein and 600 calories. The net result of these low protein-fat rations was
that by the morning of Mar. 26 the blood bicarbonate had risen to 52.8 per cent.
On Mar. 28, the diet was sharply reduced to 16 gm. protein and 10 gm. carbohy-
drate. The blood alkalinity fell sharply as on a fast-day; i.e., to 40 per cent on the
morning of Mar. 29. Beginning Mar. 29, the diet was limited to green vegetables.
On this, by the morning of Mar. 31, the CO2 capacity had risen to 44 per cent,
though the carbohydrate intake had amounted to only 30 gm. on Mar. 30. By
Apr. 7, the plasma alkalinity had risen to within normal limits on low protein-fat
diet. Thereafter it remained generally at a low normal level. No reason is
known for the low reading of 45.6 per cent on June 27, unless it were the in-
creased fat intake. By July 7, it had returned to normal without the aid of
alkali, possibly with the aid of the small allowance of carbohydrate. The other
tests were not parallel with the plasma bicarbonate. The ammonia nitrogen
at first fell from 3.4 gm. on Mar. 20 to 1.94 gm. on Mar. 22, then remained nearly
stationary to Mar. 27, thus corresponding to the plasma bicarbonate. But
when the plasma bicarbonate fell at the beginning of the vegetable period, the
ammonia fell also. Later, on protein-fat diet, the ammonia was a more sensitive
indicator of acidosis than the plasma bicarbonate, being unduly high (Apr. 14,
June 6 to 8) at times when the plasma bicarbonate was approximately normal.

192 CHAPTER m

The ferric chloride reaction became negative early in the vegetable period, at
the very time when the plasma bicarbonate fell. It remained negative thereafter.

Blood Sugar. — ^The fall during the initial period of fasting and undernutrition
is evident from the graphic record. Subsequently it rose, and remained much
of the time in the neighborhood of 0.2 per cent. The decline to a nearly nor-
mal value shortly before discharge is in conformity with the other improvement.

Weight and Nutrition.— Weight at admission 39.3 kg.; i.e., the same as at the
previous discharge. Weight at discharge 35.2 kg. Nearly 4 months of treat-
ment thus represented undernutrition to the extent of 4.1 kg. This under-
nutrition was imposed especially at the beginning of this hospital period. -From
Apr. 18 to discharge there was an actual gain of 1 kg. During most of the time
one egg was allowed on fast-days, but beginning with July the fast-days were
made absolute. The daily allowance of 70 gm. protein, 10 to 15 gm. carbohydrate,
and 1800 calories was thus reduced to an average of 60 gm. protein and 1540
calories (1.7 gm. protein and 44 calories per kg.).

Remarks. — The carbohydrate tolerance test Mar. 28 to Apr. 4 showed an assimi-
lation not above 60 gm. carbohydrate. Glycosuria also appeared subsequently on
protein-fat diets lower than those previously tolerated. Very decided downward
progress was thus clearly demonstrated in consequence of violations of diet,
during less than 2 months at home, the violations being said to have been limited
to less than 1 month. Susceptibihty of this case to rapid downward progress
on dietary overstrain is thus proved. On the other hand, in nearly 4 months
of hospital sojourn this time, the progress was demonstrably upward. From
Apr. 18 onward, as mentioned, there was a gain of 1 kg. weight, and at the same
time the patient became able to remain free from glycosuria and ketonuria on
diets decidedly higher in protein, fat, and carbohydrate than those on which
glycosuria repeatedly occurred earUer in the period. The tendency of the blood
sugar likewise was downward. Furthermore this improvement occurred in spite
of grossly excessive diets, the tendency to spontaneous upward progress being
thus all the more remarkable. In extenuation of the diet only two excuses can
be offered. One is that the patient was taking heavy exercise, and it had not
yet been learned that this does not atone for excessive diet. The other is that
it was known that the patient at home would not adhere to any diet which kept
her at all hungry or uncomfortable. Accordingly she was allowed this diet, on
which her progress seemed at least temporarily favorable, in preference to a
more beneficial diet which would be more Uable to be violated.

Fourth Admission. — Sept. 11, 1916. (No graphic chart.) Patient returned to
hospital with the usual history of having broken diet. Heavy sugar and ferric
chloride reactions were now present on her former diet. A 4 day fast was neces-
sary. A carbohydrate test with green vegetables in the usual manner showed a
tolerance of 50 gm. A carbohydrate-free diet was then begun, with 40 gm. pro-
tein and 600 calories. The experiment was then performed of keeping this pro-
tern the same while gradually increasing fat to make a totalof 1300 calories (see

CASE ItECOEDS 193

Chapter VI). The result was glycosuria, while the ferric chloride reaction re-
mained negative. Thereafter with less fat (900 to 1200 total calories) and the
same protein, glycosuria was absent, but returned when the protein was in-
creased to SO to 65 gm. She was discharged on Dec. 4, 1916, stiU in fair subjective
health.

Acidosis. — The COj capacity of the plasma at first was 35.5 per cent. Weak-
ness and malaise, making her imfit for work, were the only clinical symptoms of
acidosis. With 4 days of fasting, the CO2 capacity rose to 53.3 per cent. After 2
days respectively of 10 and 20 gm. carbohydrate, it was 59.5 per cent, and at the
close of the carbohydrate test (Sept. 22) 58 per cent. This reaction to fasting is
noteworthy ia a patient who on previous admissions had shown such decided
falls in blood bicarbonate on fasting. Likewise the heavy ferric chloride reaction
diminished on fasting and cleared up during the vegetable period. The am-
monia nitrogen, which was 3.3 gm. on the prescribed diet, dropped to 2 gm.
at the close of fasting, and to 0.43 gm. on the fast-day (Sept. 23) following the
vegetable period. Thereafter on protein-fat diets the plasma bicarbonate re-
mained at a high normal level (59.8 to 68.8 per cent) and the ferric chloride reac-
tion continued negative. The ammonia nitrogen ranged from 0.8 to 1.5 gm.,
and was thus the most delicate index of acidosis.

Blood Sugar. — This was 0.218 per cent in whole blood and 0.238 per cent in
plasma on the first day of fasting (Sept. 13), 0.192 per cent in plasma on the last
day of fasting (Sept. 16). It was never brought lower than 0.122 per cent in
whole blood and 0.147 per cent in plasma. The last analysis, with sugar-free
urine, showed 0.202 per cent plasma sugar.

Weight and Nutrition. — ^Weight at admission 41 kg., part of which was edema.
Weight at discharge 34.3 kg. The final weight was thus only about 1 kg. less
than at the previous discharge, but otherwise the condition was much worse.
The carbohydrate test above mentioned indicated a loss of only 10 gm. tolerance.
A truer index is afforded by the fact that traces of glycosuria now tended to ap-
pear on relatively low carbohydrate-free diet. In contrast to the 70 gm. protein,
10 to 15 gm. carbohydrate, and 1800 calories tolerated at the former discharge,
the diet at discharge this time had to be limited to 45 gm. protein and 1200 calories
(1.3 gm. protein and 35 calories per kg., reduced by the weekly fast-days to 1.1
gm. protein and 30 calories average). Moreover, marked hyperglycemia was con-
tinuous on this diet as stated, and glycosuria appeared upon very slight increase
of either protein or fat. The patient had again demonstrated how rapidly she
could progress downward with improper diet in the short period of 2 months at
home. At this discharge she was distinctly weaker than ever before, though still
comfortable and able to do housework. The treatment had not been radical, but
she had been fed during the whole of this hospital period to the limit of her
tolerance in order to keep up her weight and strength.

Subsequent History. — A note received from the family Mar. 14, 1917, stated that
the patient died at 2:30 a.m. that day. She had again broken diet because of the

194 CHAPTER III

unfavorable environment, and the diabetes took its natural rapid course. She
refused the petitions of her family that she return to the hospital.

Remarks. — ^The patient had been kept alive and almost uninterruptedly com-
fortable for 3 years under treatment. In view of her state of intelligence, will
power, and environment, this was probably as much as could have been accom-
plished unless she had been kept continuously in an institution. The chief
scientific interest in the case lies in its demonstration of rapid downward progress
with dietary indiscretions, and complete absence of downward progress and
distinct tendency to upward progress even under treatment which never was
radical enough to remove the continuous evidences of slight metabolic overstrain.

CASE NO. 3.

.Female, unmarried, age 26 yrs. American; no occupation. Admitted May
23, 1914.

Family History. — Father was never strong, and died when patient was 5 years
old. Autopsy is said to have revealed numerous intestinal ulcers. His parents
lived to healthy old age. Patient's mother is alive and well; her father died at age
of 28 of tuberculosis said to have resulted from a career of dissipation; also her
brother died of tuberculosis, and her sister with acute melancholia. Patient
has one brother aged 32 who suffers from nervousness and indigestion. No
diabetes or other family diseases known.

; Past History. — ^Healthy life in excellent hygienic conditions, but numerous in-
fections. Measles, mumps, chicken-pox in early childhood. Typhoid at 8.
Tonsillitis at 16 with recurrent attacks in following years until right tonsil was re- '
moved 3 years ago. Only a little sore throat since then. S years ago " colitis"
for 10 days; fever, vomiting, and dull aching pain in upper abdomen, consider-
able bloody diarrhea, no jaundice. Several slight attacks of grippe, the last
about 3 years ago. 4 years ago, "intercostal rheumatism;" in bed about a
week, no herpes. Quiet life; no overstudy, but considerable social activities in
recent years, and some exhaustion after attending several dances in the same week.
Not nervous. Worry and loss of sleep for some time following unhappy love
affair 4 years ago, but this has entirely passed off. Moderate appetite, but she
has eaten even more candy than the average girl.

Present Illness.— Jan. 12, 1914, after having been in apparently perfect health,
patient woke up with malaise and slight abdominal pain. The attack subsided
with fasting and bed- rest, but on account of slight tenderness and rigidity,
laparotomy was performed on Jan. 14, revealing obliterative appendicitis and
blood clots about right ovary, treated by removal of appendix and one ovary.
Incision healed per primam, but IS days after operation phlebitis occurred, first in
left leg, then in right. Left leg has required bandaging until recently. Urine was
reported normal in hospital, but it is doubtful if tests for sugar were made.
Weakness and weariness felt at this time were attributed to convalescence and
the patient went to summer resorts to recuperate. Polyphagia, polydipsia and

CASE RECORDS

195

polyuria began, and most of her luxuriant hair fell out. The normal weight of
120 pounds diminished to 109 pounds. 2 weeks before admission, diabetes was
diagnosed. The laboratory reports showed 8.3 per cent sugar and heavy ferric
chloride reaction. A diet was prescribed containing considerable starch. Since
then, rapid dimming of vision has been noticed. Menstruation has continued.

TABLE IV.

Diet.

Urine.

Date.

Protein.

Fat.

Carbo-
hydrate.

Alcohol.

Calories.

Volume.

Sugar.

NHj-N

Acetone

3odies (as

fl-oxy-

butync).

IDM

gm.

gm.

gm.

gm.

cc.

gm.

gm.

gm.

May 24

82.8

127.5

127.7

7.5

1854

2010

47.2

1.39

2.27

" 25

126.5

175.0

272

4.0

3259

2470

68.0

1.06

2.31

" 26

:

Fast-day.

35.0

245

910

4.2

0.88

0.88

" 27

tc

25.0

175

644

0

1.00

1.63

" 28

4.2

0.8

25

—

122

825

0

1.15

1.93

" 29

10.9

2.5

60

—

302

934

0

1.23

0.64

" 30

37.0

9.5

162

—

8*8

1700

7.99

1.31

2.08

" 31

11.6

2.7

52

—

421

1362

4.22

0.34

1.05

June 1

7.0

1.2

22

—

125

1106

0

0.38

0.21

" 2

6.2

1.4

16

99

957

0

0.46

0.45

" 3

10.8

3.7

37

—

222

866

—

0.54

0.41

" 4

24.7

10.1

98

—

568

1008

0

0.53

0.37

" 5

Fast-day.

30.0

210

1758

0

0.35

0.74

" 6

14.0

1.8 1 98

—

474

774

—

0.55

0.80

" 7

Fast-day.

30.0

210

1325

0

0.32

0.35

" 8

14.0

1.7

85

—

419

727

0

0.67

0.88

" 9

31.7

6.4

144

—

779

2009

4.31

0.74

0.69

" 10

40.1

13.6

147

—

893

2278

4.57

0.43

0.48

" 11

43.7

15.1

150

—

932

2728

4.19

0.55

0.5S

" 12

1.6

—

7.8

25.0

220

2054

0

0.35

0.41

" 13

43.2

10.4

113

—

735

1969

0

0.41

0.23

" 14

40.1

11.7

124

—

778

2060

0

0.27

0.33

" 15

38.5

7.8

136

—

787

1878

0

0.26

0.31

Physical Examination. — Height 161.3 cm. Patient appears rather juvenile for
her age; stiU well nourished, and with look of perfect health. Mouth and teeth
in good condition. Right tonsil missing, left appears normal. No enlarged
lymph nodes. Reflexes normal. Examination otherwise negative.

Treatment. — (No graphic chart.) An observation diet was first permitted simi-
lar to what the patient had been taking. The initial treatment is shown in
Table IV.

196

CHAPTER in

The most disturbing symptom was the blurred vision. The patient compared
it to the efiEect of atropine. In the early days in hospital she became unable to
read even with glasses. An oculist found no organic change, and vision rap-
idly cleared in parallel with the urine. After an uneventful period of hospital
observation without return of any symptoms, the patient was discharged on
July 24.

Acidosis. — This was never heavy, and was easily controlled by reason of the
high carbohydrate tolerance. The only alkali used was 20 and IS gm. sodium
bicarbonate respectively on the &st 2 days in hospital.

Weight and Nutrition. — Weight at admission 46.5 kg., at discharge 43.4 kg.
The apparent reduction of weight was thus 3.1 kg., but actually must have been
somewhat more, as the dried tissues recovered their normal water content during
undernutrition after cessation of glycosuria. The treatment was characterized
by low protein, low calory diets, as liberal as possible in carbohydrate. At
first such diets were exclusively vegetable. Glycosuria at first resulted from
140 gm. carbohydrate, but by June 16, 171 gm. carbohydrate were taken without
glycosuria. One egg was then added to the diet; and after June 22, 200 to 225
gm. carbohydrate could be taken daily without glycosuria. As a precaution,
however, the allowance was diminished to 150 gm. The diet prescribed at dis-
charge represented approximately 70 to 80 gm. protein (largely vegetable), 150
gm. carbohydrate, and 1200 to 1500 calories (1.5 to 1.75 gm. protein and 26 to 33
calories per kg., without fast-days). As the patient was about 9 kg. below nor-
mal weight, this allowance was considered prudent; and she was permitted to
estimate her diet instead of weighing it, on condition that she be guided by her
body weight and not allow herself to gain much flesh. She was stiU sufiiciently
well nourished to look and feel entirely healthy. The degree of undernutrition
in hospital, and the extent to which fat was excluded and carbohydrate empha-
sized in the diet, can be shown by the following table.

Total.

Average per day.

Calories in diet for 61 days

61,287
2,788.7 gm.
2,073.1 "
7,121.0 "

1005

Protein " " "61 "

45.7 gm.
34 0 "

Fat " " " 61 "

Carbohydrate " " "61 "

117 0 "

Nitrogen in diet for 61 days (Protein -f- 6.25)

446.0 gm.
278.6 "
266.5 "

7 ^ CTTYl

" " " " 49 " ( " ■^6.25)

5.68 "
5 44 "

" in urine "49 "

" " " per kg. per day (average 44 kg.)

0.125"

It should be borne in mind that the diet was strictly vegetarian, chiefly green
vegetables, except for a single egg daily after June 16. A considerable propor-
tion of the protein was therefore non-absorbable, so that the close correspondence

CASE RECORDS 197

between food and urine nitrogen must be attributed not to unusually good utili-
zation of food, but rather to loss of body nitrogen. Protein restriction to this
degree was doubtless unnecessary, but the rigid undernutrition was a commendable
feature.

Subsequent History. — The patient led a thoroughly normal and comfortable life,
but managed her diet so as to permit a gradual gain in weight. Occasional traces
of glycosuria returned, and these and the gain in weight were not checked by mod-
erate exercise which was advised. Presumably eating was increased in propor-
tion to the exercise. During the 2 years outside the hospital the patient had
been married and divorced, and though the glycosuria was attributed partly to
worry, it probably was essentially of dietetic origin. The predominant difficulty
consisted in traveling and hotel life, where vegetables were often cooked with
starch and even sugar. Though feeling perfectly well, she reentered the hospital
for observation on request.

Second Admission. — ^Jime 6, 1916. Weight 49.2 kg. The urine showed a
trace of sugar which cleared up readily without fasting. The carbohydrate
tolerance was not accurately tested, but was evidently somewhat lower than
before.

The patient was dismissed June 20, weighing 48.1 kg., on a diet of 60 gm.
protein, SO gm. carbohydrate, and ISOO calories, with fortnightly fast-days.
The first blood sugar analyses were made during this period, and showed a ten-
dency to slight hyperglycemia.

Subsequent History. — The patient remained free from glycosuria while keeping
house for herself. She then traveled again and gained moderately in weight.
The traces of glycosuria which finally returned were again due to unintentional
irregularities in diet in hotel life.

Third Admission. — Apr. 16, 1917. Weight 46.4 kg. Heavy glycosuria, slight
ferric chloride reaction, ammonia nitrogen 1 .96 gm. , blood sugar 0.317 per cent, CO2
capacity 46 vol. per cent. Glycosuria continued on the diet formerly prescribed,
but ceased with a single fast-day, Apr. 22. A carbohydrate test thereafter
showed a tolerance of only 50 gm. The acidosis meanwhile cleared up. A
carbohydrate-free diet was then instituted, with 65 gm. protein and 1200 cal-
ories. On this there was an excretion of 0.8 to 1 gm. ammonia nitrogen daily.
The last blood examination on May 23 still showed hyperglycemia of 0.176 per
cent. The patient was discharged May 30, 1917, weighing 45.8 kg., on the diet
above mentioned (1.4 gm. protein and 26 calories per kg.). She was to return to
the hospital within a few months for observation to determine whether these meas-
ures were adequate.

Remarks. — One feature of interest is the possible origin of the diabetes from
an infection or operation. Possibly this was no more than an exciting cause.
At any rate, the diabetes was permanent. The case was of the most acute type
and the progress very rapid, so that physicians had given a prognosis of only a
few months of life. The actual result has been an approximately normal exist-

198 CHAPTER III

ence for SJ years to date. The principal trouble has been that the life was too
nearly normal. Though the patient was strictly faithfiil in her intentions, she
led a rather strenuous life and exceeded her diet quantitatively in such manner
that the weight was not held down to the desired degree of undernutrition. The
greatest difficulty has been the prolonged life in hotels, where undue quantities of
carbohydrate were eaten unintentionally. Such causes of injury are very serious
in a case inherently so severe and so susceptible to harmful influences. In addi-
tion, there is the fact that the tendency to hyperglycemia was not detected and
checked in its incipiency. These various causes suffice to account for the clearly
perceptible downward progress. Comparison between the great rapidity of such
progress before beginning treatment, and its slowness during more than 3 years
of still imperfect treatment, casts doubt upon the existence of any "spontaneous"
cause. The patient is stiU comfortable and looks the picture of health. The
more rigorous dietary restrictions now necessary will reduce her considerably in
weight and strength, and it remains to be seen whether they will succeed in
arresting the downward tendency.

CASE NO. 4.

Male, age 12 yrs. American; no occupation. Admitted June 22, 1914.

Family History. — Mother is well. Two of her grandparents died supposedly of
Bright's disease, at age above 60. Her father died supposedly of typhoid at
62. Her mother died of cancer of the stomach at about the same age. Her
only brother and sister are living and well. Father's grandparents died in old
age. Father's mother died of heart trouble at above 70 years. His father died
after 60 with some form of nervous and mental trouble along with glaucoma.
An uncle of the father died at the age of 6 years of diabetes. Two brothers of
the father died, one in Europe at the age of 21, supposedly from overstudy, the
other of some nervous or mental trouble in a sanitarium. The father is the only
survivor of his family and is neurotic. Patient's parents married when the
mother was 19; she had two children 13 months apart and had typhoid when
the first baby was 1 month old; no miscarriages. The first child developed
diabetes at the age of 2| years and died from it at 4 years.

Past History. — Patient had normal birth. Mother's milk disagreed and baby
was raised on artfficial food. At the age of 2 months, history of swelling of both
sides of neck; incisions on the two sides said to have liberated enough pus to fill a
drinking glass; no return of anything of the sort. The baby was healthy and fat,
but not abnormally obese. Several attacks of bronchitis in infancy, "rheuma-
tism" in the legs for 4 days when 4 years old, measles at 5, chicken-pox at 6,
several attacks of tonsillitis thereafter, but no complaint of tonsils in recent years.
In general a bright, healthy, active boy. He attended school for 2 years, there-
after was taught by governess at home. Candy was forbidden from fear of
diabetes, otherwise an ordinary diet was taken with ordinary quantities of
starch.

CASE RECOEDS 199

Present Illness. — Polyuria and polyphagia began at the age of 5, and diabetes
■was immediately diagnosed by family physician. Diet was restricted by with-
drawal of sugars and most starches, substituting gluten bread, but through
more than a year of such treatment patient never became sugar-free. A diabetic
specialist was then consulted and glycosuria was kept absent for several weeks.
Acidosis was found about this time, and a small amount of carbohydrate was then
allowed. He remained under careful treatment up to the age of 9, but felt so
badly and lost so much weight on carbohydrate-free diet that a change seemed
necessary. He was then given liquid diet, taking two or three quarts of milk a
day, but glycosuria became so heavy that strict diet was resumed within a few
days. One such period has been tried since; otherwise a moderately restricted
diet in weighed quantities has been taken. The usual oat cures, preceded and fol-
lowed by vegetable days with eggs have been used repeatedly, but no fast-days.
The patient's highest weight was 70 pounds at the age of 10. Up to the age of
1 1 the urine had been free from albumin so far as observed. At that time both
glycosuria and acidosis became worse, and urine showed considerable albumin and
casts. Nephritis has been present ever since, with more or less edema most of
the time. Vision began to be blurred several years ago and was not aided by
glasses. About a year ago there began to be a mist before his eyes, which has
increased to nearly total bhndness. The hair has been falling out since about
the same time. Teeth have not decayed, but have failed to develop; two ca^-
nines appeared about a year ago and barely protruded beyond the gums. Con-
stipation is complained of, also attacks of vomiting. Coma has been, seriously
threatened on two occasions and has been averted by the free use of carbohy^
drate and alkali. A number of different climates and mineral springs have been
tried without result. Neuritic pains in the legs are also complained of, and on
two occasions recently sUght superficial injuries have produced long-standing
ulcers, one of which is barely healed. The gums are said to bleed whenever the
teeth are washed. The patient has been bed-fast for a month or more on ac-
count of weakness, but recently has been sitting up and dressed for a few hours
daily.

Physical Examination. — Height 140 cm., weight 23.8 kg. Extreme emacia-
tion and weakness. Hair cream-colored, long, silky, thin. Eyelids droop with
look of exhaustion; intraocular tension diminished. Pupils react to both light
and distance, but tests of vision show that only marked changes in illumination
are perceived and only large objects dimly distinguished. Vision better at
periphery than at center of fields. Ears and nose normal. Mouth shows above
mentioned condition of teeth, well kept, but tongue moderately coated. Palate
and fauces narrow; only slight tonsillar enlargement. Palpable glands in neck,
very small. A few sudamina especially on sides of neck. Otherwise skin is dry
and slightly scaly. Knee jerks barely obtainable, other reflexes normal. General
examination otherwise negative.

Treatment. — On June 23 and 24 diet was permitted according to description of

200 CHAPTER in

what had previously been taken. Fasting was begun with some misgivings on
account of the extreme weakness, and whisky was administered in the small
quantities which the patient could take without complaint of discomfort. By
June 27 the strength seemed greater rather than less. Nevertheless as a pre-
caution, since fasting had not heretofore been imposed upon any patient as danger-
ously weakened as this, it seemed conservative on this day to allow 155 gm.
olive oil with a trifle of vegetables as a rehsh. Alcohol was given the next day,
and on the following days olive oil was again added. Green vegetables were then
added, representing carbohydrate as follows: July 1, 6 gm.; July 2, 12 gm.; July
3, 15 gm. A change was then made to protein-fat diet, increasing up to 61.6
gm. protein and 1530 calories on July 13. Pancreas was fed at this time as noted
below. This diet was tolerated as far as glycosuria was concerned. The bare
traces of glycosuria Umited to certain portions of the day, which appeared so en-
tirely unaccountable at that time, were explained subsequently as due to sur-
reptitious eating, in this instance probably of a sweetened tooth-paste. On ac-
count of these traces of glycosuria and the persistent acidosis, an absolute fast
was imposed notwithstanding weakness, and continued for 5 days, being followed
by the alcohol day of July 19, and then by a limited protein-fat diet, always below
900 calories. By the end of this period, Aug. 7, the strength was far better than
at any previous time. The patient was up and dressed most of every day,
walked about the hospital, and on Aug. 7 was strong enough for an automobile
ride. Beginning Aug. 9, a period of very low diet consisting largely of alcohol
and green vegetables was instituted, particularly for the purpose of clearing up
acidosis, until on Aug. 17 one egg was added to the whisky and vegetables. The
diet was increased by one egg daily, tiU on Aug. 20 four eggs were given. After
a fast-day with alcohol on Aug. 24 and a vegetable day on Aug. 25, protein-fat
diet was begim and rapidly increased to 1600 to 1700 calories, with as much as
SO to 60 gm. protein. Glycosuria was stopped by the fast-days (with alcohol) of
Sept. 5 and 6, but returned promptly with resumption of the high diet. It also
persisted during the 2 alcohol days, Sept. 16 and 17, and the low protein-fat diet of
SOO calories or less of the latter part of Sept. and the &st of Oct., but cleared up
■when a diet was subsequently given composed of little more than alcohol and
olive oil. The patient became very weak in consequence of this undernutrition.
On Oct. 19 he woke up weak, but with normal consciousness. While he was
eating breakfast consciousness gradually failed, and within less than an hour he
was entirely unconscious. Pulse and respiration showed no special change.
Tube feeding was instituted, a total of nine eggs and 30 cc. whisky being given in
divided doses. Saline solution was given intravenously at intervals, and three
doses of 10 gm. levulose each in 200 cc. solution were given subcutaneously. Bene-
fit was only temporary, and death occurred after very gradual decline on Oct.
20, with continued imconsciousness but no other signs of diabetic coma and with
urine negative for both sugar and acetone bodies.
Acidosis. — The patient entered with a daily excretion of approximately 18 gm.

CASE RECORDS

201

total acetone bodies (as |8-oxybutyric) and 2.5 gm. ammonia; these were brought
gradually to an almost normal level. A slightly high ammonia and occasional
traces of ferric chloride reaction persisted. Radical treatment of the acidosis
was difficult because of the extreme weakness of the patient.

The results of attempting to maintain strength by the use of fat are shown in
Table V.

Oil days instead of fast-days were tried at the outset as shown, because of their
use by former workers and because of the patient's weakness. The first and

TABLE V.

Diet.

1

fe.

6

S

3

o
gm.

4J

u

i

Urine.

Date.

1

i

1

1

1

1

i

I

CC.

i

1
*3

3

1

U (A

Hi >,

III

1914

em.

gm.

gm.

gm.

gm.

gm.

gm.

gm.

June 23

70.5

101

4.15

—

1623

23.8

—

—

3174

42.51

11.59

1.65

8.00

" 24

91.5

177

103.3

—

2319

23 .'2

—

— .

2772

32.60

10.64

3.44

15.59

" 25

—

—

—

16.5

116

23.2

3

—

2953

12.96

6.67

2.75

9.22

" 26

—

—

—

19.5

137

22.3

—

—

2361

6.85

5.15

2.60

7.67

" 27

6.9

248

11.9

1.2

1578

22.4

—

—

2028

16.30

5.17

2.33

17.81

"" 28

2.3

2.3

1.9

25.5

189

21.2

20

. —

2074

8.90

5.68

2.70

8. 95

" 29

—

50.0

—

26.0

632

22.0

—

5

2238

1.17

3.18

1.80

2.99

" 30

—

80.0

—

22.0

874

21.6

—

20

2483

0

3.50

1.79

4.77

July 1

2.1

102.6

5.8

20.0

1125

21.6

—

20

2153

+

3.61

2.37?

3.25

" 2

5.3

110.0

12.7

10.0

1201

21.0

—

5

1589

0.66

3.18

2.07

2.10

" 3

4.5

12.5

15.3

22.5

353

21.4

—

—

1324

3.92

2.70

1.32

4.35

" 4

7.6

38.0

—

21.2

532

21.6

—

—

1501

-1-

3.33

1.08

7.03

" 5

15.4

12.1

—

11.2

625

21.2

—

—

1340

0.80

3.08

2.20

8.19

" 6

15.4

52.1

—

17.5

669

21.6

—

—

1574

0.97

2.44

1.65

4.35

" 7

22.6

58.1

—

17.5

731

21.4

—

—

2855

0.36-1-

5.47

1.62

7.45

" 8

22.6

58.1

■ —

17.5

731

21.8

—

20

1736

-1-

2.83

1.15

7.23

u 9

22.6

58.1

—

17.5

731

22.6

—

—

2453

-t-

3.48

1.52

5.80

" 10

22.6

58.1

—

17.5

731

22.8

—

—

2749

+

3.33

1.48

5.87

" 11

30.8

82.2

—

17.5

1012

23.2

—

—

2769

+

3.75

1.47

11.66

" 12

30.8

82.2

—

17.5

1012

23.4

—

20

2467

+

4.29

1.26

6.26

" 13

61.6

124.4

—

17.5

1531

23.2

—

18

2768

+

7.94

1.55

6.28

« 14

Fast-day.

—

23.5

—

—

1031

-t-

3.25

0.59

3.37

" IS

u

1.5

23.0

—

—

1082

0.46

2.49

0.62

4.92

" 16

iC

22.6

—

—

1225

0.22

2.47

0.70

3.24

" 17

(t

22.0

—

—

1263

0

"2.70

0.69

0.79

" 18

tt

21.6

—

—

1130

0

1.92

0.28

1.46

" 19

u

12.0

21.6

—

—

1322

0

1.98

0.27

1.09

202 CHAPTER m

largest of such fat rations, on June 27, caused the acetone body excretion to rise
suddenly from 7.67 to 17.81 gm. The next day, without fat, there was an equally
sudden fall to 8.9S gm. The influence of smaller quantities of fat on subsequent
days was less clearly distinguishable, but the general effect was an elevation
of the ammonia and acetone body output, as shown especially by the fall with
fasting after July 13, It is thus evident that even moderate quantities of in-
gested fat keep up acidosis, presumably by maintaining a higher fat metabolism
than on fasting. Also, strength is not improved by such use of fat. On the
contrary, acidosis tends to produce more marked asthenia than undernutrition.
The occasional alkali dosage is shown in Table V. Perhaps the reason for the
absence of increase of ammonia excretion with the high fat intake of June 27, is
that the ammonia formation was already at the maximum possible in this patient
at this level of total nitrogen excretion. Possibly the lack of neutralizing sub-
stance was responsible for the marked clinical symptoms of acidosis (hyperpnea,
prostration, small rapid pulse) which came on promptly toward the close of
that day. It therefore seemed advisable to give 20 gm. sodium bicarbonate
on the next day. Calcium carbonate might theoretically neutralize acid in the
stomach and perhaps to some extent in the intestine. It is not known whether
it served any practical usefulness in this or other cases where it has been tried.
No other alkali was given except toward the close of the history; then on 6 days
(Oct. 8 to 13) without s3rmptoms suggesting acidosis and merely with a vague
idea of guarding against salt starvation, the following mixture was given daily:
sodium bicarbonate, calciimi carbonate, magnesium oxide, each 2 gm., potassium
bicarbonate, 1 gm. The giving or withholding of such mixtures has had no per-
ceptible influence upon this or other patients. Vegetables presumably furnish
sufficient quantity and variety of bases.

Tolerance. — This was exceedingly low, but an exact estimate of it is prevented
by slips in the diet. At the outset, the barely perceptible traces of glycosuria
in the early days of July seemed perplexing. Later, unaccountable glycosuria
was encountered on certain days without clear relation to the known food in-
take. It had seemed that a blind boy isolated in a hospital room and so weak
that he could scarcely leave his bed would not be able to obtain food surrepti-
tiously when only trustworthy persons were admitted. It turned out that his
supposed helplessness was the very thing that gave him opportunities which
other persons lacked. Even on a diet which satisfied his appetite according to
his own statement, as at the end of Aug. and the first of Sept., the attempt to
evade the strict watch kept over him appealed to him as a sort of game or battle
of wits, so that he even took things for which he had no real desire. Among these
unusual things eaten were tooth-paste and bird-seed, the latter being obtained
from the cage of a canary which he had asked for. Also his mother and his
governess on visiting him sometimes brought lunch, which was kept in a closet
supposedly without his knowledge; nevertheless, in the short intervals when he
was unwatched, he managed to find it and remove such articles as might not be

CASE RECORDS 203

missed. These facts were obtained by confession after long and plausible denials.
The experience illustrates what great care is necessary if records of diabetic
patients are to be vouched for as correct.

Weight and Nutrition. — Weight at admission 23.8 kg., at discharge 18.1 kg.
One feature is the successful carrying through of two periods of inanition in a
dangerously weak, small boy. The olive oil, as mentioned, probably did more
harm than good. The whisky may have been of some slight aid, but there was no
plain clinical evidence. The 6 days of almost complete fasting beginning July 14
were borne without signs of collapse, even though the weakness was such as to
cause concern before any fasting was imposed. The diet of some 700 to 800 cal-
ories, protein, fat, and alcohol, in the latter part of July and the first part of
Aug., was theoretically sufficient for maintenance, but was barely tolerated.
Even though some of the glycosuria may have been due to slight errors in diet,
the recurring traces of ketonuria show that this intake was excessive. The
period of carbohydrate and alcohol beginning Aug. 9 cleared up the ketonuria,
but did not avail to prevent its prompt return when a high carbohydrate-free diet
was next attempted. The diet of 1600 to 1700 calories at this time was very
high for this body weight; there was in fact a slight gain of weight and strength,
but as usual the increasing glycosuria and ketonuria forced a cessation of this
plan, and the end-result, as is invariably the case, was harmful instead of bene-
ficial. The subsequent undernutrition beginning Sept. 16 was improperly planned,
because the persistent glycosuria apparently indicated a remarkable absence of
assimilation, whereas the real trouble was the unusual ingenuity of the patient in
obtaining forbidden food.

Pancreas Feeding.— This patient developed a liking for raw pancreas, so that he
spontaneously asked for it. It was therefore of interest to study the effect of a
diet in which pancreas protein was the sole possible source of sugar; i.e., a diet
composed of nothing but pancreas, olive oil, and alcohol. This was the character
of the diet beginning July 4; on that day SO gm. of fresh pancreas weregiven as
the only protein. The next day this was increased to 100 gm., which continued
to July 7, when it was raised to 150 gm. This continued to July 11, when it was
increased to 200 gm. On July 13 the quantity was increased to 400 gm. The
traces of glycosuria were not cleared up either by pancreas or by fasting until
the patient's trick of eating a small quantity of tooth-paste each morning was
detected, whereupon on July 17 the traces of sugar ceased promptly. It is there-
fore evident that pancreas feeding did not avail to establish an assimilation for
even the trivial quantity of sugar contained in a very few grams of tooth-paste.
On July 20, after fasting, the first diet given consisted of 80 gm. fresh beef pancreas
with whisky and olive oil. On July 21 the pancreas was increased to 120 gm.
On July 22 it was only 96 gm. by mistake, on July 23, 120 gm. On July 24 and
25 the identical diet was given, with substitution of raw beef for pancreas. On
July 26 and 27 the same quantity of beef was given, cooked before eating. On
July 28 and 29, 120 gm. of raw pancreas were again substituted. The occasional
glycosuria up to this time was irregular and probably due to surreptitious eating.

.204 CHAPTER in

This diet was apparently near the verge of tolerance. After a fast-day on July
30 the same diet was given, of 120 gm. pancreas with addition of one egg; this diet
continued to Aug. 8. A regular and persistent glycosuria was the result, evidently
■due to the fact that this diet was slightly in excess of the tolerance. It would
therefore appear that fresh pancreas was not able to increase the patient's protein
tolerance to the extent of one egg, since he was mostly sugar-free on pancreas or
raw or cooked beef without the egg, and excreted small quantities of sugar on raw
pancreas with addition of the egg. There was also no perceptible influence upon
acidosis. Another pancreas feeding experiment was tried, begiiming Sept. 10,
with similar result (see Chapter IV).

Remarks. — This 12 year old patient, admitted after 7 years of downward prog-
ress, delayed but not stopped by the most competent care obtainable, with reti-
nitis and profound emaciation and weakness, may be said to have been in the hope-
less stage of his disease. It is of interest that both albumin and casts cleared up
under treatment; they may therefore be attributed to the diabetes or perhaps
:to the acidosis, since true nephritis does not thus disappear. The weight was
reduced by 5.8 kg. in the 4 months of treatment. The improvement in strength
was evident to all concerned and considerable encouragement was felt at one time.
The essential difficulty lay in the stealing of food; on account of this deception
the treatment was improperly managed in several respects. The undernutrition
period of the closing month was what brought on death, which may be attributed
to inanition.

It seems unprofitable to speculate how long or in what condition this patient
might have hved if he could have been treated by undernutrition from the first
-diagnosis of diabetes. What is certain, however, is that diabetic retinitis has
never yet been known to develop under thorough treatment by this method; and
anyone making use of high diets for the sake of supposed comfort must be pre-
•pared to assume responsibihty for occasional blindness and similar troubles.

CASE NO. 5.

Male, married, age 34 yrs. American; customs inspector. Admitted July
15, 1914.

Family History. — Entirely negative for heritable or metabolic disease.

Past History. — Generally healthy life. Measles, tonsiUitis, and adenoids in
childhood. Neisser infection at 22. No history or indications of syphiUs. Ner-
vous and easily excitable since boyhood. Indigestion and constipation began at
about 22 and have grown worse up to the present, probably aggravated by irregu-
lar eating since entering customs service at 23. There is a feeUng of hunger with
nausea between meals, temporarily relieved by eating; no pain, no vomiting, little
• eructation. No alcohol up to 25, then began to drink beer and other liquors,
occasionally to sUght excess; during the past 4 months has lost all appetite for
liquor. Smokes two or three cigars a day.

Present Illness.— In July, 1913, while at work, patient experienced a sudden
-feeling of dizziness, then compression about chest, followed by vomiting, colic,

CASE RECORDS 205'

and diarrhea. After a doctor had given him calomel and salts at home, on diag-
nosis of "autointoxication," he had hot fever during that night, but felt well the
next day and returned to work. Urine was not examined. From that time on
he felt constantly thirsty and steadily lost weight and strength. About Sept. 1
the same doctor was consulted again and found 4 per cent glycosuria. Patient
followed the routine restricted diet prescribed, but was sugar-free only twice for
about a week; this sugar-freedom was obtained by rigid exclusion of carbohydrate.
Acetone appeared, so a small quantity of carbohydrate was allowed, with result-
ing glycosuria. Occasional vegetable days have been employed. Lately a quart
of mUk daily has been added, and diet has been unrestricted on 1 day each week..
On vacation in the country, July of this year, he took ordinary mixed diet for 1
week, and experienced an acute attack similar to the initial seizure 1 year pre-
viously. At present he follows the diet with restricted carbohydrate; feels ner-
vous and weary, no polyphagia, slight polydipsia and polyuria; no dryness of skin,
but on the contrary troublesome sweats. Normal weight has been 175 to 18&
pounds; recently it has fallen to 144 pounds.

Physical Examination. — Height 1 73.8 cm. Weight 60.4 kg. Body well formed,
but lean. Neurasthenic manner, expression indicating weakness and weariness.
Skin very moist, noticeable pallor. Slight enlargement of tonsils. Knee jerks-
entirely absent. Other reflexes normal. Examination otherwise negative.

Treatment. — On the day of admission and the 2 following days, patient was
allowed to choose a diet resembling his habitual one. Then 2 plain fast-days were
given, followed by 3 alcohol days. The result, as shown in the graphic chart,
was a clearing up of glycosuria but persistence of the ferric chloride reaction.
Green vegetables were then added (July 23 to 27) and the latter reaction thus
cleared up. After a single fast-day with alcohol on July 28, the patient proved
able to tolerate a diet as high as 1100 calories with about 50 gm. protein and 70
to 75 gm. carbohydrate. This was undernutrition, representing, for a body weight
of about 60 kg., about 0.9 gm. protein and less than 20 calories per kg. Alcohol'
was discontinued on Aug. 5, as it was unnecessary and the formation of a habit
was undesirable. Beginning Aug. 11, an experimental period was begun to show
the effect of increasing calories, particularly in the form of fat (see below) . There-
after, it was intended to place the patient upon a proper hving ration preparatory
to dismissal; but on Nov. 9 he suddenly requested discharge to accept a particu-
larly favorable business opportunity. He was therefore allowed to go with
approximate instructions regarding diet, following the plan of not weighing his-
food but judging portions by the eye, and guiding himself by his urinary tests and
particularly by his weight. The diet ordered consisted of protein, fat, and about
100 gm. carbohydrate in green vegetables. The entire treatment was not one of
undernutrition, because he left weighing approximately 1 kg. more than on adibis-
sion to hospital. The relative mildness of the diabetes had not called for the-
most rigorous measures, and the patient was already far under normal weight..
He was instructed never to allow himself to gain weight above 160 pounds.

206

CHAPTER lU

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CASE RECORDS

207

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TABLE VII.

Diet.

Urine.

J

OJ

Date.

,

« .

tn U)

1

'Sd

^

S

I.S

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1914

««.

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gm.

cc.

gm.

em.

Sept. 29

26.4

7.3

82.0

511

8.7

58.8

1375

+

+++

8.06

-4.13

+82.0

" 30

26.3

7.2

82.2

511

8.5

60.0

1975

0

+++

10.51

-6.69

+82.2

Oct. 1

26.2

5.9

75.6

471

7.7

60.8

3035

0

+++

6.80

-2.89

+75.6

" 2

25.7

7.3

80.9

513

8.4

60.6

2900

+

++

5.92

-2.10

+80.9

" 3

26.1

7.4

80.4

504

8.3

60.6

2995

0

+++

8.69

-8.98

+80.4

" 4

24.4

6.6

82.5

499

8.3

60.0

2715

0

+

7.06

-3.43

+82. S

" 5

32.5

13.0

80.0

582

9.6

60.2

3380

0

+

9.06

-4.22

+80.0

" 6

40.1

16.8

73.2

620

10.3

60.0

3195

0

0

8.56

-2.69

+73.2

« 7

44.9

57.8

80.1

983

16.3

60.0

2315

+

0

—

+80.1

" 8

45.5

51.6

84.3

1010

16.5

61.0

2590

0

0

8.38

-1.61

+84.3

" 9

46.1

51.7

82.3

1006

14.7

61.4

3205

0

0

8.46

-1.58

+82.3

" 10

45.5

51.6

84.3

1010

16.4

61.6

2615

0

+

7.95

-1.17

+84.3

" 11

51.5

56.3

82.6

1072

17.3

62 jO

2795

0

0

—

+82.6

" 12

S8.7

61.8

77.0

1129

18.1

62.4

2960

0

0

8.88

-0.14

+77.0

" 13

65.2

96.0

82.0

1495

23.6

62.2

2822

0

+

8.81

+0.98

+82.0

" 14

69.1

128.5

82.1

1814

29.1

62.4

3150

0

0

9.45

+0.83

+82.1

" 15

75.2

163.2

82.1

2161

34.4

62.8

3145

0

0

9.12

+2.05

+82.1

" 16

75. 5

187.3

82.4

2392

38.1

62.8

2895

0

0

7.30

+3.84

+82.4

" 17

81

189

105

2518

39.9

63.0

4280

0

0

9.93

+2.11

+ 105.0

" 18

92

196

104

2621

41.6

63.0

3380

0

0

8.92

+4.76

+ 104.0

" 19

104

195

99

2643

41.9

63.0

3270

0

0

10.20

+5.27

+99.0

" 20

103

194

103

2647

41.7

63.4

3960

0

0

11.56

+3.78

+ 103.0

" 21

104

195

103

2661

42.0

63.4

3160

0

0

10.49

+4.99

+ 103.0

" 22

110

203

124

2851

45.0

63.4

4070

0

+

—

+5.38
(calc.)

+ 124.0

" 23

114

197

121

2646

41.7

63.4

3680

0

0

11.48

+s:49

+ 121.0

" 24

114

220

118

2999

47.0

63.8

4254

0

0

15.31

+ 1.64

+ 118.0

" 25

114

228

120

3073

48.4

63.4

4085

0

0

15.36

+ 1.61

+ 120.0

" 26

113

219

119

2829

44.7

63.2

4487

0

0

14.36

+2.47

+ 119.0

" 27

115

221

123

3128

50.0

62.8

3590

0

+

_

+ 123.0

" 28

112

227

118

3053

48.3

63.2

3810

0

0

_

+ 118.0

" 29

114

228

120

3074

48.8

63.0

3554

0

+

_

+ 120.0

" 30

81

222

39

2556

—

—

1605

0

0

_

+39.0

" 31

78

368

51

3950

—

—

930

0

+++

_

+51.0

Nov. 1

108

193

92

2610

39.4

62.2

3770

0

0

+92.0

" 2

148

292

92

3676

59.8

61.4

3205

0

+

_

+92.0

" 3

165

483

104

5595

90.8

61.6

2865

+

++

_

+104. 0

" , 4

165

482

99

5563

89.4

62.2

2600

+

+

,

+99.0

" S

112

351

93

4099

65.9

62.2

3090

0

+

_

+93.0

" 6

Alcohol 2C

'gm.

140

61.6

2690

0

0

" 7

155

221

119

3177

53.6

59.2

2240

0

0

_

+ 119.0

" 8

114

220

120

3002

48.8

61.4

3880

0

0

_

+120.0

" 9

114

220

120

3002

49.0

61.2

1710

0

0

-

-

+ 120.0

208

CASE RECORDS 209

Overfeeding Experiments. — The patient was peculiarly adapted to experiments
with excessive diets, for though he had never suffered from true diabetic poly-
phagia, he was habitually a very heavy eater. Also his constipation was invinci-
ble, notwithstanding the most enormous fat diets. He took these diets with
relish and without increase of his slight dyspeptic complaints. As indicated in the
laboratory chart, the stools were small, hard, and infrequent, and carmine for de-
marcation was always retained for several days. With the return of diabetic
symptoms in each instance the patient felt so much worse that he was glad to re-
sume a rational diet even at the price of slight continual hunger. The experi-
ments were of practical usefulness in convincing him of the inadvisability of try-
ing to satisfy his appetite, and with this object lesson he has remained faithful to
treatment from that time to the present.

Nitrogen Balance. — The most surprising feature is the remarkable nitrogen
retention, comparable to that described in normal persons by Liithje and in dia-
betics by Falta and coworkers. It is to be recalled that the patient was moderately
emaciated from diabetes and had then been subjected to fasting and low diet,
which had reduced his nitrogen excretion to a low level. Also the diet ia this ex-
periment was liberal in protein, and starting at 64.5 calories per kg. increased to
109 calories per kg. — an extreme surplus for a man at rest in a hospital ward.
With the rapid gain in weight it is not surprising that considerable nitrogen was
stored, but it is remarkable that the low output of 6 to 8 gm. daily was main-
tained up to the sudden increase on Sept. 13, the day before the onset of glyco-
suria, and simultaneously with the appearance of the first decided ferric chloride
reaction. The retention then continued, but to a diminishing extent, notwith-
standing the steady increase in total calories. The diminution of storage may
probably be attributed to the active diabetic symptoms. Notwithstanding the
large quantity of nitrogen stored, the fasting and low diet following Sept. 27
quickly brought a return to the same low nitrogen output as before. Analyses
are not complete for the second period of overfeeding, but the data available
fuUy confirm the results in the first period.

Influence of Body Weight. — The weight was built up in two feeding periods on
different diets. Diabetic symptoms were present at the higher weight in each
instance. The attainment of a higher weight in the second as compared with
the first period of overfeeding may have been aided by the mildness of the symp-
toms on the second diet. This difference makes it clear that weight was not
the sole factor in bringing back symptoms, but the kind and quantity of the
different elements of the diet is necessarily an important factor.

Influence of the Diet. — Both glycosuria and acidosis were brought on by in-
crease of the diet, particularly in fat. The influence of the three elements may
be considered as follows.

1. Carbohydrate. — The glycosuria cannot be attributed merely to carbohy-
drate, because the increase of carbohydrate in the first overfeeding period was
not great, and the quantity on certain days, such as Sept. 23, 25, and 26 with

210 CHAPTER in

heavy glycosuria was actually less than on earlier days without glycosuria. Also
in the second overfeeding period the carbohydrate was regularly higher than in
the first one, yet glycosuria was trivial in comparison with the first period. On
the other hand, carbohydrate was not effectual in preventing acidosis, so that
it would have been impossible, even in this relatively mild case, to control acidosis
by feeding carbohydrate along with a high fat diet. A fallacy of the carbohydrate
balance plan is also illustrated; for in the period Sept. 11 to 19 this balance was
as high as before, yet the beginning ferric chloride reactions and the higher average
acetone excretion, though so slight as to be often ignored, were actually significant
of the damage already done by fat and soon to be more manifest.

2. Protein. — Protein was increased at the time of glycosuria and acidosis in
the overfeeding period. Such increase did not prevent acidosis. The gener-
ally higher protein may be regarded as one cause of the heavy glycosuria in the
first overfeeding period, as compared with the slight glycosuria in the second.
On the other hand, protein can scarcely be credited as the sole cause of the gly-
cosuria, since the latter was out of proportion to the increase of protein in the
first overfeeding period, and also on certain days of the second period {e.g. Nov.
3 and 4), with sUght glycosuria, both protein and carbohydrate were higher than
on certain days in the first period {e.g. Sept. 20, 23, 25, and 26) with very heavy
glycosuria.

3. Fat. — The principal increase in the diet was in the form of fat, and to this
may be attributed most of the gain in weight and return of all diabetic symp-
toms. The fat diet was much higher in the first than in the second overfeeding
period, and the excessive caloric intake in this form may be considered the most
important factor in the production of both glycosuria and acidosis. Periods of
fasting and lower diet quickly cleared up both the laboratory and the clinical
symptoms.

4. Calorimetry. — ^This patient was studied by Dr. Eugene DuBois in the
respiration calorimeter of the Russell Sage Institute of Pathology on Oct. 30 and 31
and Nov. S, with a view to observing any possible anomalies in the disposal of
the huge rations, particularly of fat. No departures from the normal were demon-
strated either in the basal metabolism or in that following a heavy fat meal.'

Subseqiient History. — ^The patient remained at work in excellent condition, until
he reported at the hospital on Dec. 28 weighing 160 pounds, glycosuria having
come on with the increase in weight without change in the prescribed diet. Fast-
ing and reduced diet at home brought him down to 157 pounds, but a trace of
sugar returned on Jan. 10. He was therefore instructed to keep his weight there-
after below 155 pounds. He then remained continuously sugar-free until he re-
ported at the hospital on Mar. 21 with the following history. On account of
his slight indigestion he had consulted a well known stomach specialist of New
York, who told him that he must omit most of his vegetables and take two white

1 Cf. Allen, F. M., and Du Bois, E. F., Arch. Int. Med., 1916, xvii, 1010-1059.

CASE RECORDS 211

rolls daily. The patient objected that this would bring back his glycosuria,
but the physician responded that he had better have glycosuria and feel better.
The patient therefore took the white rolls for a short time, and promptly showed
heavy glycosuria. He then on his own judgment stopped the rolls, cleared up the
glycosuria by fasting, and reported at the hospital because his tolerance had
been lowered and he now showed traces of sugar on the diet on which he was for-
merly sugar-free. A reduction of his green vegetables was therefore ordered, and
he was instructed not to exceed his existing weight, which was then ISO pounds.
At this weight he was reasonably weU nourished and fully able to work, and his
troubles were all classified as neurasthenic.

On Apr. 2 and again on Apr. 9, the patient reported, showing both sugar and
ferric chloride reactions and weighing 149 pounds. The vegetables were ordered
thrice boiled so as almost entirely to exclude carbohydrate from the diet, and the
quantities of food were now more strictly regulated so as to make a ration of
approximately 2500 calories.

On June 19, the ferric chloride reaction was negative, but there had been traces
of glycosuria from time to time.

On July 13, he returned with a similar report, but had recently caught cold,
and this had brought a return of glycosuria, concerning which he was very nerv-
ous. He was therefore readmitted to the hospital for the week July 13 to 19
for purposes of instruction. Physical examination was as before, except for en-
largement of the hver to 5 cm. below costal margin. He was placed on a diet
of approximately 2100 calories, with 90 gm. protein and 30 gm. carbohydrate
(see graphic chart). He was discharged with instructions to weigh all food,
adhere rigidly to this diet, and take a fast-day once every week.

On Aug. 8, he weighed only 58.8 kg., and complained of weakness, weariness,
and hunger, but had shown no sugar since leaving hospital. Bran muffins were
added to relieve both his feeling of emptiness and his constipation.

On Feb. 28, 1916, the report was similar. He was walking 6 mUes daily for
exercise. On this basis his diet was increased to 108 gm. protein, 30 gm. carbohy-
drate, and 2400 calories. Thereafter he continued at work with favorable re-
ports until June 5, when the carbohydrate was increased to 40 gm. and the cal-
ories to 2500. Traces of glycosuria gradually came on, so that on July 17 the
carbohydrate was again reduced to 30 gm.

The urine subsequently remained free from both sugar and ferric chloride
reactions, and the patient gradually increased his exercise to 8 miles of walkiag
daUy.

On May 23, 1917, the weight was 56 kg., the blood sugar 0.116, and the car-
bon dioxide capacity of the plasma 59.9 per cent.

On June 13, 1917, the weight was still 56 kg. and diet was 20G0 calories, with
50 gm. carbohydrate and 70 gm. protein. The blood sugar was 0.155 per cent,
and the carbon dioxide capacity of the plasma 64 per cent. The urine remained
negative for sugar and ferric chloride reactions.

212 CHAPTER III

Remarks.— This was one of the early cases, and the treatment contained errors
accordingly. The diabetes was of moderate severity, and the attempt was made
to treat it with as little inconvenience to the patient as possible, insisting upon
a normal urine and a moderately reduced body weight, and hoping for a recovery of
assimilation under these conditions. The result shows that such loose methods
are not advisable even in a case of this type, and that tolerance is lost rather than
gained under such a plan. The patient had felt unable to work at the time of his
first admission to hospital. He has been kept in working condition during most
of the time for 3 years. His tolerance has fallen sUghtly, so that now about
80 gm. carbohydrate is tolerated with a diet of 2200 calories. The blood sugar was
never reduced to normal, as might easily have been done, and the slight downward
progress seems to be nothing inherent in the nature of the condition, but rather
due to the inadequacy of the treatment and the continuous shght overtaxing of the
assimilation. On the whole, a prolonged and conscientious attempt was made to
treat this case from the standpoint of immediate comfort and efficiency, and the
record is now believed to show that this treatment is unjustifiable even for a case
apparently as well suited for it as this one.

Recent examinations have shown that the liver, which was normal in out-
line at the first examination, and afterward was obviously enlarged in examinations
by different observers several months apart, is now distinctly subnormal in size.
The superficial veins of the abdomen are becoming prominent. The diagnosis
of cirrhosis seems evident, progressing through the hypertrophic to the atrophic
stage. This has not suppressed the diabetes and dietary care should not be
remitted, but the most rigorous measures appear unnecessary. The frequency of
pancreatitis in connection with cirrhosis of the liver is worthy of investigation.

CASE NO. 6.

Female, married, age 48 yrs. Italian; housewife. Admitted July 23, 1914.

Family History. — Indefinite. Patient is ignorant of any special disease in
family. (Husband, short and obese, is said to have developed mild diabetes
siince this patient's discharge.)

Past History. — Very healthy life. Patient keeps house for her husband and
four children. Six children died young, perhaps because of tenement conditions.
One of those living is mentally defective. Menses regular up to 1 year ago,
absent since. She drinks four glasses of beer, one cup of coffee, and one cup of
tea a day. Other habits are those of an industrious poor Italian woman.

Present Illness. — Patient was admitted on the pneumonia service on July 23,
1914.

Physical Examination. — ^A short, slightly obese woman with sturdy peasant
appearance, and normal on physical examination except for consoHdation and
pther signs of pneumonia of right lower lobe. The urine showed heavy sugar and
ferric chloride reactions, though there had been no former complaints indicating
diabetes.

CASE RECORDS 213

Treatment was conducted first by the pneumonia service of the hospital. The
temperature fell by lysis on the 5th, 6th, and 7th days, and on July 31 the signs
in the right chest had cleared up and the patient was turned over to the diabetic
service.

During the period of pneumonia the diet consisted of oranges and egg-nogs
with whisky and cream, the caloric intake being about 1400 to 1600, as shown
in the graphic chart. Glycosuria and ketonuria remained heavy during this
time as indicated, but there were no symptoms threatening coma.

Diabetic treatment was begun on Aug. 1 with fasting, with addition of whisky
because of the convalescent condition. She thus received about 600 calories of
alcohol daUy until Aug. 7 to 8. She was a very unwilling patient during this
time, having been content to stay in the hospital during the pneumonia, but now
that she felt well, she was determined to go home to her babies. She had never
heard of diabetes and was accordingly unwilling to be treated. Her husband was
'of equally ignorant type, but fortunately he and certain relatives had seen a
few deaths from diabetes and comprehended the necessity of dietetic treatment.
Accordingly she consented to remain until completion of treatment. On Aug.
8, green vegetables were added to the whisky and gradually increased until on
Aug. 14 they represented 80 gm. carbohydrate. The next day one egg was
given, Aug. 17 two eggs, Aug. 18 three eggs, Aug. 19 four eggs, and the next
■day 100 gm. fish were added. A ration was thus gradually buUt up amount-
ing to some 1400 to 1700 calories, with 100 gm. carbohydrate and almost the
same quantity of protein. This seemed to be an adequate but not excessive
diet for her body weight of 54 kg., and it was tolerated without glycosuria
or ketonuria. She received several days' instruction in the diet kitchen in the
preparation of her food. She was not required to weigh it, but was ordered to
take the same kinds and quantities at home as she had been receiving in the
hospital.

Acidosis.— A small point is noteworthy regarding the effect of alcohol. On
fasting with whisky the ferric chloride reaction became absent on Aug. 3, and
the glycosuria the next day. With continuance of 600 calories of alcohol daily,
the ferric chloride reaction reappeared on Aug. 6. 600 calories of alcohol there-
fore did not suffice to keep it absent. It cleared up on Aug. 13 in consequence
of the addition of green vegetables to the whisky, about 50 gm. carbohydrate in
this form sufficing for this result.

Subsequent History. — ^After dismissal on July 31, nothing more was heard from
the patient until Nov. 25, 1914, when she called at the hospital by request, bring-
ing a specimen of normal urine and reporting that she had followed her diet faith-
fully and that daily urine tests had been uniformly negative. Circumstances pre-
vented testing the carbohydrate tolerance at that time.

Nothing more was heard from her until she was finally located by the
visiting nurse and called at the hospital by request on July 5, 1917. The urine
:showed heavy sugar and negative ferric chloride reactions. The patient claimed

214 CHAPTER in

to feel entirely weU but looked pale and run down. She admitted that she had
abandoned diet shortly after her previous report and since then had eaten starches^
sugars, and the regular family diet without restriction. She was advised to
reenter the hospital and resume treatment, but refused on the ground that her
children required her presence at home.

Remarks. — ^The case is chiefly noteworthy from having been first discovered
during an acute infection. Presumably diabetes had been present without notice-
able symptoms before this time. It was evidently aggravated as usual by the
infection. The case is essentially mild and readily controllable by treatment, but
the patient's ignorance and neglect are responsible for continuance of active
symptoms, which may be expected to bring serious trouble within a few years.

CASE NO. 7.

Female, married, age 36 yxs. American; clothing saleswoman. Admitted
July 23, 1914.

Family History. — Father died at 52 of heart trouble. Mother alive and
healthy. All grandparents lived to old age. Five brothers and two sisters of
patient alive and well. No diabetes or other family disease known.

Past History. — ^Healthy life, but obesity from childhood. Only sickness scar-
let fever. At the age of 15 patient weighed 135 pounds; before onset of present
trouble, her weight was 168 pounds. At 18 she began work as a clothing sales-
woman; married at 33 but continued work. No children; one miscarriage. Un-
happy married life ending in separation. Habits said to be regular, alcohol de-
nied. Patient was a light eater all her life and also indulged very little in candy
or sweet dishes. Since onset of diabetes, for thirst and to stimulate strength,
she has taken coffee to excess, at least 20 cups a day, 1 pound of cofiee every 2
days. Nervous since onset of diabetes but not before.

Present Illness. — Symptoms began last Dec. with pruritus vulvae. A physician
made an examination and prescribed a local application without testing urine.
She and her friends noticed rapid loss of weight, and she applied at the Board of
Health for examination for tuberculosis, which was found absent. She then
went to a medical school clinic, where the physician in charge diagnosed diabetes
and merely gave her a list of things to eat and to avoid. During 4 months' at-
tendance at the clinic no benefit was received, and pruritus vulvae and loss of
weight continued. Since Mar. there has been constant pain in calves of legs,
described as like toothache. Within the past few weeks she has had six styes
on the left eye, which healed uneventfully. Much of her hair has fallen out.
There is polydipsia and polyTiria but no pol3T)hagia.

Physical Examination. — ^Nutrition still medium, though superficial tissues
show flabbiness and wasting. Nervous facies and behavior. Posterior cervical
glands slightly enlarged. Vagina and surroimding parts show superficial in-
flammation. Uterus retroflexed retroverted. Examination otherwise negative.
Wassermann reaction negative.

CASE RECORDS 215

Treatment. — For the first 3 days, the patient was allowed an observation diet
Tunning as high as 115 gm. protein, 80 gm. carbohydrate, and 2000 calories. On
this her highest sugar excretion was 63 gm. The ferric chloride reaction, whicL
was slight on admission, became heavy on this diet, indicating that the former
diet had included more carbohydrate. 2 days of absolute fasting were then im-
posed. The glycosuria ceased but the ferric chloride reaction remained heavy.
The next day 100 gm. lettuce and 100 gm. cucumber were allowed. Green vege-
tables were increased daUy without other food untU 33 gm. carbohydrate were
;given in this form on July 30. The ferric chloride diminished to a shght reac-
tion, but glycosuria appeared. A fast-day with 35 gm. alcohol was then given,
and as glycosuria immediately ceased, 27 gm. carbohydrate in the form of green
vegetables were given the next day for the sake of acidosis. Glycosuria ap-
peared, but the carbohydrate was continued for 2 days. Then Aug. 3 was a fast-
•day with 70 gm. alcohol. On Aug. 4, 12 gm. carbohydrate were given as green
vegetables, and on Aug. 5, 17 gm. The ferric chloride reaction had been di-
minishing and was now absent. Although glycosuria remained absent, Aug. 6
and 7 were fast-days with respectively 65 and 87 gm. alcohol. A slight ferric
•chloride reaction returned. On Aug. 8, 90 gm. alcohol and 5.8 gm. carbohydrate
(in green vegetables) were given. On Aug. 9, the alcohol was increased to 120
gm. and the carbohydrate to 16 gm.; Aug. 10, alcohol 105 gm., carbohydrate 17
gm.; Aug. 11, alcohol 90 gm., carbohydrate 22 gm. The alcohol was then dimin-
ished to, 75 gm. and this program was continued to Aug. 16. The ferric chloride
reaction had been well marked under the large doses of alcohol at the beginning
of this period, but gradually diminished with the introduction of carbohydrate
untU it became negative. On Aug. 17 one egg was added, on Aug. 20 a second egg.
A slow increase of diet was continued, until on Aug. 27 it included four eggs, 200
gm. meat, and green vegetables representing 41 gm. carbohydrate. Both glyco-
suria and ketonuria were now continuously absent, the exclusion of fat having
been the principal means by which this end was attained. Fat was then gradu-
ally introduced, finally making a diet of about 100 gm. protein, 60 gm. carbohy-
drate, and 2100 calories. Slight glycosuria resulted and the diet was therefore
•diminished to 80 gm. protein and 1700 calories.

The patient began to keep irregular hours on visits outside the hospital and
was absent one whole night, returning with glycosuria. On Sept. 28 she went
out and failed to return. She reappeared on Dec. 7 showing 3.3 per cent glyco-
suria, which easily cleared up. She visited friends on Christmas and did not
■return for 2 days. Therefore on Dec. 27 she was dismissed for this conduct, and
no further tracing of her case was attempted. ' The impression was received that
the patient was a drug addict or an occasional alcoholic, and that her behavior
was thus explained, but no real proof of this supposition was obtained.

Acidosis. — ^The only noteworthy feature is the fact that doses of alcohol from
75 to 120 gm. failed to clear up the ferric chloride reaction or prevent its reap-
pearance. The efficient means of stopping the persistent acidosis was found in

216 CHAPTER III

continued undernutrition and carbohydrate up to the limit of tolerance, with-
abstinence from fat.

Remarks. — The initial treatment consisted in continuous undernutrition with
as much carbohydrate as possible. After both glycosuria and ketonuria were
thoroughly controlled, the diet was built up by the gradual addition of first pro-
tein and then fat. The weight at entrance was 52.8 kg. The lowest weight re-
sulting from the undernutrition was 47.9 kg. on Aug. 19. Thereafter it gradu-
ally rose, and at the time of her first leaving on Sept. 28 the patient weighed 50
kg., which was a satisfactory state of nutrition for both comfort and strength.
The case illustrates the treatment of diabetes of moderate intensity with the aid of
only the simplest laboratory tests. The outcome was satisfactory except that
the psychic instability of the patient precluded continuing treatment.

CASE NO. 8.

Male, married, age 29 yrs. American; printer. Admitted July 28, 1914.

Family History. — Father and mother are alive and well. Mother had a goiter
removed at age of 40 for cosmetic reasons; there were no symptoms. Grand-
parents all healthy. Patient is the oldest of six children. No diabetes or other
family diseases.

Past History. — Healthy life. Measles, mumps, and chicken-pox in childhood.
Always took cold easily; never had sore throat. Slight pleurisy 4 years ago; irk
bed only 1 day. Regular life; no excesses Never nervous. Married 1 year ago;
wife well, never pregnant.

Present Illness. — In June, 1913, immediately upon return from honeymoon^
patient noticed abnormal thirst and dryness in mouth. Physician immediately
diagnosed diabetes but merely prescribed a diet list, and condition rapidly grew
worse. Patient was then referred to a New York physician who ordered a diet of
nothing but ham and lettuce. He lived strictly on this diet for 6 weeks, eating
as much as 5 or 6 pounds of ham a day. Sugar diminished but did not disappear.
Other treatments were tried with a steady downward progress. He then con-
sulted a New York specialist, who placed him on strict diet with one " green day""
each week, and three or four teaspoonfuls of sodium bicarbonate daily. The-
urine was never sugar-free, and the loss of weight and strength became worse^
On July 25, 1914, patient entered a New York hospital, where a D : N ratio of
3 : 1 was demonstrated on carbohydrate-free diet. Coma threatened on this diet^
but the addition of a slice of bread seemed to make him worse. He was then-
transferred to this hospital in critical condition.

Physical Examination. — An emaciated man appearing very weak. Face thin,
and nervous. Skin dry. Acetone odor. Drowsiness and increased respiration
very evident. Knee jerks absent. Physical examination otherwise negative.

Treatment. — For the first 4 and a fraction days in hospital, the patient was
placed on an observation diet as nearly carbohydrate-free as convenient, thrice
cooking of vegetables having not yet been adopted. This diet, which represented

CASE RECORDS 217

77 to 135 gm. protein, 6 to 12 gm. carbohydrate, and 2800 to 3300 calories, was
all the patient could eat. He showed the usual inability to gain weight or strength
on full feeding, and clinical evidences of acidosis increased. 20 gm. sodium bicar-
bonate and 20 gm. calcium carbonate were given daily. By Aug. 2 there was in-
cipient coma with nausea, continuous dozing which was promptly resumed when-
ever patient was roused, hyperpnea, malaise, and weakness. Fasting was there-
fore begun from necessity. Whisky was given in 10 cc. doses hourly, amounting
to about 100 gm. alcohol on the various fast-days. Calcium carbonate 20 gm.
and sodium bicarbonate 30 gm. were given on Aug. 2. On Aug. 3 the bicarbon-
ate was increased to 40 gm., on Aug. 4 it was diminished to 20 gm., and on Aug. 5
all alkali was stopped. Clinically, meanwhile, the condition seemed to grow worse
during the first 24 hours of fasting; the sleep was noticeably deeper. Improve-
ment on the following day was marked and all the threatening symptoms cleared
up rather suddenly. Sugar-freedom resulted on Aug. S, the 4th day of fasting,
although the D : N ratio had been 3 : 1 on the feeding days. Because of the
marked weakness, whisky was continued in doses just short of producing intoxi-
cation, and green vegetables were gradually added, beginning Aug. 7 with 100 gm.
each of lettuce and cucumbers. On Aug. 10 the quantity of carbohydrate in this,
form amounted to 38. S gm., and by reason of 240 cc. whisky, the total calories for
this day were 1073. TherewasadayofwhiskyaloneonAug.il. The program
of alcohol and green vegetables was continued to clear up acidosis thoroughly,
and 40 to 50 gm. carbohydrate were now assimilated daily without glycosuria.
The ferric chloride reaction was abolished, but the patient was ravenously hungry
and seriously weak. Accordingly, on Aug. 23 the carbohydrate was stopped, and
the diet consisted of 4 eggs, 100 gm. butter, and 135 gm. alcohol. The eggs were
then increased and the alcohol diminished daily, until on Aug. 27 the diet was 60
gm. protein, 37.5 gm. alcohol, and 1660 calories. Aug. 28 was a "green day" of
nothing but alcohol and green vegetables with 55 gm. carbohydrate. This sort of
program continued until Sept. 11. As usual, no benefit to weight or strength re-
sulted from the attempt to feed to the limit. Accordingly, on Sept. 12 a lower
diet was begun, carbohydrate-free, with 80 gm. protein and 1300 calories, the alco-
hol being at the time diminished to 20 gm. daily. For the weight of about 35
kg. this meant less than 30 calories per kg. daily, and this was diminished still
further by the fast-days every 1 or 2 weeks. Exercise would presumably have
been beneficial, but the tradition was followed of keeping a patient with severe
diabetes as quiet as possible. Therefore he was weak and cold and spent most
of his time in a chair close to the radiator, clad in heavy clothing and double
underwear. Nevertheless, the condition at certain times began to appear rather
promising, since the sugar and ferric chloride reactions were frequently both nega-
tive. A difference from the average case soon began to be noted, in that sugar
kept unaccountably reappearing and the tolerance seemed to be perceptibly fall-
ing under conditions when it should have risen or at least remained stationary.
With the progress of time it became more evident that something unusual was

218 CHAPTER ni

breaking the patient down. Dr. Joslin chanced to see the patient on a visit and
suggested the presence of tuberculosis, but physical signs and sputum examina-
tions remained negative. Dec. 6 to Jan. 1, pancreas and duodenal feeding were
attempted without benefit, as described elsewhere (Chapter IV). Thereafter
the attempt at radical treatment of the diabetes was abandoned, and the patient
was allowed at times to eat his fill of a selected diet. Although this diet amounted
sometimes to 60 or 70 calories per kg., there was the usual absence of benefit
to weight or strength, and the attempt to overfeed was doubtless a mistake.
Certain days of lower diet and occasional fast-days were necessarily inserted be-
cause the increasing acidosis sometimes threatened coma. On Jan. 9 he was
transferred to the metabolism ward of the Russell Sage Institute of Pathology at
BeUevue Hospital for calorimetric studies by Dr. Eugene DuBois.' He returned
to this hospital on Jan. 15. The diet of 2000 calories or over during most of
Jan. failed to prevent further loss of both strength and weight . Both the weakness
and the rapidly falling weight were probably associated with the seriously increas-
ing acidosis. The steep elevations in weight shown in the graphic chart at times
in this same period represented marked edema due to sodium bicarbonate in doses
up to 80 gm. daily. Nevertheless on Feb. 1 the point had been reached where a
choice was necessary between fasting and immediate death in coma. A 6 day
fast with whisky was accordingly imposed, which stopped the glycosuria and
cleared up the threatening symptoms, though the ferric chloride reaction was not
made negative. A lower diet was then employed, mostly about 30 calories per
kg., on which glycosuria remained almost continuously absent and greater comfort
was enjoyed by reason of the absence of acidosis symptoms, though the patient
was very weak. On Mar. 16 the patient had the symptoms of catching cold
with fever and pain in the chest. Some dulness and crepitant rMes were now de-
tected. On account of the aggravation of the diabetes, fasting with alcohol was
employed on Mar. 16 and 17, but the glycosuria increased. The D : N quotient
on Mir. 16 was 2.3, on Mar. 18 it was 4.6. As death was imminent, the attempt
at dietary restriction was abandoned and a liberal protein-fat diet with alcohol
was permitted. By Mar. 22 the weakness had become extreme. Though there
was chemical evidence of intense acidosis, the patient never went into typical
coma. Death occurred at noon on Mar. 22, 1915; the patient recognized his
wife shortly before this, though too weak to speak.

Acidosis. — The intense acidosis during the first days in hospital was mentioned
above. On Aug. 1 the excretion of ammonia was 3.5 gm. and that of acetone bodies
(expressed as ;8-oxybutyric acid) was 38.6 gm. A rapid fall was evident even in
the first 24 hours of fasting. On Aug. 8, with 16 gm. carbohydrate in the diet,
the excretion was still 1.1 gm. ammonia and 3.1 gm. /?-oxybutyric acid. It is
noteworthy that the period of 20 days up to Aug. 23, with a diet composed solely
of alcohol and green vegetables in the quantities shown, failed to clear up the
acidosis entirely, as indicated by the excretion of 0.76 gm. ammonia nitrogen and
0.48 gm. /S-oxybutyric acid on Aug. 22. If allowance be made for the effect of the

CASE RECORDS 219

40 to 50 gm. of carbohydrate, which was assimilated without glycosuria, it would
seem that no evident antiketogenic effect, was exerted by approximately 600
calories of alcohol in the diet daily. A specific character of the acidosis perhaps
is recognizable in such cases, by comparison with others in which acidosis is
absent on similar regimen. Neither carbohydrate nor alcohol, but undernutrition
was the essential factor in controlling the acidosis at all periods of the treatment.

With a rather high carbohydrate-free diet beginning Aug. 23 there was a
marked rise in ammonia excretion, showing the harmful effects of the attempt to
build up strength or weight above the tolerance. With the low diet which began
Sept. 11 there was a gradual improvement, so that even without carbohydrate in
the diet the ferric chloride reaction became entirely negative on Oct. 7, and no
more than traces reappeared during the time of radical treatment. Early in
Dec, when the attempt was begun to nourish liberally on account of the assumed
infection, there is another marked rise in the acidosis, going higher as the attempt
was prolonged, until on Jan. 20 the ammonia excretion reached 5.1 gm. In con-
sequence of 2 fast-days it fell sharply, then rose to 4.62 gm. on Jan. 28 in con-
sequence of further excessive feeding. Then on fasting and lower diet it fell
and remained at a much lower level until near the end, analyses in the last few
days of life being lacking because of loss of some urine.

Beginning Jan. 25, the carbon dioxide capacity of the plasma was also deter-
mined. It is seen that although the body weight at that time was rising in con-
sequence of edema from heavy bicarbonate dosage, the blood alkalinity fell
sharply to a dangerously low level. With the fasting and alcohol beginning
Feb. 1 it rose easily within normal limits, then ranged slightly below and slightly
above the lower normal level for most of the remaining time, but dropped sharply
almost to the coma level just before the fatal end.

A statement of the alkali dosage is necessary for proper interpretation of the
ammonia and COj curves. After the stopping of alkali on Aug. 5 as above men-
tioned, no more was given until Aug. 28. From Aug. 28 to Dec. 18 inclusive, the
patient received daily 2 gm. each of sodium bicarbonate, calcium carbonate, and
magnesium oxide, and 1 gm. potassium bicarbonate. These were given in the
attempt to assure against a deficit or improper balance of any or all of these
bases, as well as to neutralize acids. Similar mixtures have been used in a few
other cases. The points in mind have been the reported wasting of bones and ex-
cretion of bone salts in diabetes, and also the vague idea sometimes suggested that
a disturbance of the balance of salts or metals is at the bottom of diabetes. No
effect of such mixtures upon the tolerance or general condition, and no advantage
over the use of sodium bicarbonate alone, have been perceptible in any of the
cases.

On Dec. 19, 6 gm. sodium bicarbonate were given, and 2 gm. on Dec. 20.
The ammonia excretion following the huge diet of Dec. 30 was less than it other-
wise would-have been, because of the giving of 6 gm. sodium bicarbonate on Dec.
30, and 15 gm. sodium bicarbonate and 30 gm. calcium carbonate on Dec. 31.

CASE RECORDS 221

Present Illness. — 1 year ago patient consulted a physician for a severe cough
which had lasted about 2 weeks, and also for a slight injury to his right knee
due to a fall. He was told that he had "lung trouble" and was sent to the
country. Here he began taking a larger diet than that to which he was accus-
tomed, and especially a great deal of cereals and starchy foods. In about 2
weeks he began to notice polyuria and polydipsia. A physician then diagnosed
diabetes. A list of carbohydrate-free foods, also " Metchnikoff 's tablets" were
prescribed. For the past 9 months he has been under treatment at one of the
best New York clinics on practically carbohydrate-free diet. The severer symp-
toms date back 4 or S months, during which time he has lost 25 pounds in weight,
has grown much weaker, and his cough has become worse. Constipation and
abdominal cramps have been jnarked, with nausea and sometimes vomiting.
There is a chronic cough, mostly at night, with expectoration of white mucus
without blood. There was blood in the sputum on one occasion. He now
drinks 20 to 30 glasses of water daily and passes as much as 8 quarts of urine.
Polyphagia present. "••

Physical Examination. — ^Young man with nervous look, moderate emaciation,
and general appearance of weakness. Eyes unduly bright, face flushed, skin in
good condition. Some pyorrhea, and a few decayed teeth. Throat red, tonsils
not visibly enlarged, cervical glands not palpable. A few subcrepitant riles in
both apices posteriorly, and expiratory murmur slightly prolonged; lung sounds
otherwise normal. Organs otherwise negative. Knee jerks absent. Blood
pressure 80 systolic, 60 diastolic.

Treatment. — The patient was placed upon an observation diet of protein, fat,
and green vegetables for 4 days, as shown in the graphic chart. Glycosuria was
as high as 98 gm. on Oct. 11, but the excretion of acetone bodies was not above
1.4 gm. of /3-oxybutyric acid. Fasting with whisky was begun on Oct. 12, and
the urine became sugar-free on Oct. 15. Nevertheless, as the patient was well
able to endure fasting, green vegetables were not begun untU Oct. 18, when 6
gm. carbohydrate were given in this form, increased to 15 gm. on the next day,
30 gm. on the next, and 54 gm. on the next. Sugar was present in traces on the
last 2 days (Oct. 20 and 21), therefore 1 more fast-day with alcohol was given on
Oct. 22. On Oct. 23 the diet consisted of one egg, 30 gm. alcohol, and 600 gm.
thrice cooked vegetables. The next day was similar, with two eggs and substi-
tution of 20 gm. butter for the alcohol. Three eggs were given on Oct. 25, and
four on Oct. 26, and then fat was gradually introduced in the form of butter and
bacon. A little steak was added on Oct. 30. The highest diets of this period,
Oct. 29 to Nov. 1, were only 40 to 60 gm. protein and some 1200 to 1400 calories.
But the traces of sugar and ferric chloride reactions made a fast-day with alcohol
advisable on Nov. 2. A higher diet was then attempted, up to 2700 calories on
Nov. 12, with 17 gm. carbohydrate and 99 gm. protein. The rise in glycosuria
was controlled by 1 fast-day with whisky on Nov. 16 and 2 complete fast-days
on Nov. 30 and Dec. 1. Protein-fat diets were then employed during most of

222 CHAPTER ni

Dec. and Jan., the short high calory periods being atoned for by other days of
fasting or very low diet. The carbohydrate feeding shown in the graphic chart
for the latter part of Jan. represents caramel, which was tolerated with very little
glycosuria. It was evident from experience that the patient's carbohydrate
tolerance was practically nil, and symptoms returned with any attempt at protein-
fat overfeedmg. Therefore, in Feb. he was placed on a diet of about SO gm. pro-
tein and ISOO calories, which, if the body weight be set at SO kg., would be 1 gm.
protein and 30 calories per kg. A fast-day once a week served to reduce this by
i, making it equivalent to ? gm. protein and 26 calories per kg. Exercise had
not been adopted for such cases at that time, and this patient was kept mostly
at rest. He pronounced this diet adequate for his appetite, and was dismissed
on Feb. 17, free from glycosuria and acidosis and, in condition for taking up some
light occupation.

Subsequent History. — After several weeks experience with the diet prescribed
at discharge, the patient had professed his full ability and willingness to live
on it, and was expected to go to some nearby place in the country and report
frequently concerning his progress. No reports were received. It was learned
that he had told another patient in the ward that he was not satisfied to be re-
lieved by diet. He showed an advertisement of a proprietary remedy for diabetes
and announced his purpose to seek a complete cure. Instead of keeping his
promise to the hospital, he went immediately upon departure to a southern
state. He died in Mississippi on Apr. 17, exactly 2 months after discharge.
This information was received from a life insurance official, who was unable to
give any particulars concerning the death.

Acidosis. — The slightness of ketonuria at admission is presumably to the
credit of the treatment given the patient at the clinic in the previous months.
It was easily cleared up by the routine measures. The acetone body excretion
remained low notwithstanding the high diets in Nov., but the ammonia rose
to apfftoximately 1 gm. on two occasions. It fell after the fast-day with whisky
on Nov. 16, but the fall was particularly sharp in the 2 days of plain fasting,
Nov. 30 to Dec. 1. Acidosis was easily controlled during the hospital stay.
There was no doubt of the inherent severity of the case, however, and the prob-
able cause for death 2 months after leaving hospital symptom-free would
undoubtedly be coma.

Blood Sugar. Renal Function. — The few analyses from Oct. 11 to Nov. 2 indi-
cated that the blood sugar was rather easily brought to normal. Traces of gly-
cosuria appeared with a lower blood sugar level than usual for diabetic patients,
and the findings suggested that the kidney was rather easily permeable. This
is the more interesting in view of the fact that small quantities of albumin and
casts were present in the urine at some times. This patient was also one of
those who, from renal deficiency or unknown cause, are subject to marked
edema under treatment. The sharp rise in weight on fasting and low diet, up
to 56.2 kg. on Nov. 1, was an example of marked edema. Other peaks in the

CASE EECORBS 223

weight curve likewise are explainable as edema, sometimes not visible, but in the
marked instances plainly evident in face and extremities, with pitting about the
ankles. The rapid clearing up of edema with sharp fall in weight as shown at
various points on the chart was regularly accomplished by salt-free diet.

Remarks. — This patient was neurotic and secretive. Most of his difficulties
in the hospital were neurasthenic, and the attempts to please him were responsible
for most of the irregularities and excesses of the diet. He was admitted with
a particular view to the suspicion of tuberculosis. The cough gradually cleared
up during the diabetic treatment. In Jan. he had a 10 day attack of bron-
chitis. Examinations for tubercle bacilli on 6 days of this attack as well as on
other occasions during his hospital stay were uniformly negative. He was kept
in the fresh air most of the time and at dismissal was continuously free from
cough or any perceptible signs in the chest. The diagnosis of the pulmonary
condition is therefore uncertain.

The entire lack of ability to take carbohydrate without glycosuria on a diet
of less than 30 calories per kg. is one index of the severity of the case. Theoreti-
cally, some degree of tolerance should have been built up by more radical under-
nutrition, but the patient was not psychically suitable for thorough measures.

The treatment cannot be considered ideal in view of the dietary irregularities
and excesses. It represents undernutrition to the extent of reducing the body
weight from 53.6 kg. on admission to 47.6 kg. on discharge; i.e., a loss of 6 kg.
As a result the patient felt stronger and more comfortable, and was free not only
from the urinary signs of diabetes but also from his former subjective symptoms.
The marked neurasthenia remained. The outcome is satisfactory to the extent
that the patient was kept in a tolerable condition for S| months in hospital and
was symptom-free at the close, while the actual severity of his condition was
demonstrated by death after 2 months of unregulated diet following discharge.

CASE NO. 10.

Male, unmarried, age 17 yrs. Irish American; plumber. Admitted Nov. 7,
1914.

Family History. — Grandparents lived to old age. Parents living and well.
One brother died in infancy; one brother and three sisters living and well. No
diabetes or other disease known in family.

Past History. — Healthy, vigorous life. Measles and whooping-cough in child-
hood. No other infections; no venereal disease, alcohol, or tobacco. Has
worked hard as plumber's helper since stopping school at 14, but he was strong
and the work was no strain on him. Always a heavy eater; partiailarly candy,
ice cream, pastry, and everything sweet taken in large quantities. Normal
weight 133 pounds.

Present Illness. — Last Jan. or Feb. the patient began to drink two gallons of
water per day and pass urine correspondingly. He felt well at this time and was

CASE RECORDS 225

1000 calories was made on Dec. 29. Jan. 5 was a complete fast-day, Jan. 26 an-
other. Generally reduced diet was used instead of fast-days because of the pa-
tient's weakness. He gained strength very markedly during the course of treat-
ment and began to look and act almost like a well boy. Exercise was employed
with apparently great benefit, especially as he was naturally strong and muscular.
He walked many miles daily, went skating on the ice, and undertook other
activities.

Toward the close of Jan. he and his parents considered that a cure had been
achieved and that he was ready to go to work. As long as he felt ill he was an
ideal patient. At this time, feeling well, he began to rebel at diet and all other
hospital rules. The glycosuria and ketonuria during and just preceding the
month of Feb. are attributable not to the prescribed diet, but to violations on the
part of the patient. It became necessary to discharge him on Feb. 8, and he was
informed that in view of his conduct this hospital could have no further connec-
tion with his case. It was learned that he followed no regular diet thereafter, and
died Mar. 9 with the usual acidosis symptoms.

Acidosis. — The only alkali given was 10 gm. sodium bicarbonate on Nov. 11.
In the absence of alkali treatment the excretion of acetone bodies was relatively
low, reaching only 13.2 gm. of /S-oxybutyric acid on Nov. 10. For the same
reason the ammonia excretion was high in comparison, being 3.4 gm. on Nov.
10, 4.75 on Nov. 11, and 4.46 on Nov. 12. It is evident that fasting with alcohol
did not immediately bring about a low ammonia, but beginning Nov. 12 the
steepest fall occurred, down to 1 .5 gm. on Nov. IS, and 0.42 gm. on Nov. 20. The
clinical symptoms cleared up much more strikingly than the ammonia.

On the too abundant carbohydrate-free diet of Dec, the ammonia never fell to
a normal level. It seemed to rise quite markedly after stopping alcohol on Dec.
16, so that on Dec. 22 and 26 it was slightly above the level of Nov. 14 (2.18 gm.).
Dec. 27, with a diet solely of whisky representing 85 gm. alcohol, brought a strik-
ing drop in the ammonia, and on the lower diet following this date the ammonia
never returned to the height of this peak, but also did not fall to normal. It
could presumably have been brought down to normal by the use of alkali, but the
advisability of alkali for this purpose under the circumstances is open to question.
In this same period the ferric chloride reaction was entirely negative. Alkali
would presumably have made it positive and increased the excretion of total
acetone bodies. The desirability of this change is also an unknown matter. The
real trouble was an unsuitable diet.

Blood Sugar. — The accuracy of the single determination showing an unexpect-
edly low blood sugar on Nov. 13 is doubtful. While irregularities are possible, it
seems more probable that the blood sugar remained close to 0.25 per cent until
about the close of the fast and then it fell to below 0.15 per cent. The occasional
analyses up to Dec. 15 showed a tendency to remain within normal limits. Fur-
ther analyses were not possible at the time. More attention should have been
paid to this point. In correspondence with the improvement otherwise, it would

226 CHAPTER in

seem that the case was still at a stage when normal blood sugar values were rather
easily attainable, and such should have been insisted upon.

Remarks. — The earlier part of the treatment was well carried out, and the
patient, threatened with coma, was rapidly freed from ketonuria, glycosuria, and
hyperglycemia. This was still at an early period of experience with this method;
it had not yet been learned that apparent restoration of tolerance is not to be
trusted too far, and that weakened function does not so rapidly recover to this
extent, but that it must be continuously spared by prolonged undernutrition.
Therefore, a carbohydrate-free diet was built up too fast and too high. Even in
the absence of laboratory danger signs, it is now known that such a procedure
inevitably brings disaster later. The lower diet of early Jan. was more rational.
But in general, instead of trying to make the patient feel too well and build him
up too rapidly, a more stringent limitation of both diet and weight should have
been insisted upon. The patient was received weighing 41.6 kg. After a sharp
initial drop to 39 kg. in the early days of fasting, the weight remained stationary,
then rose sharply as a result of water retention. Even with the weight of 45.6
kg. on Nov. 28 he did not appear edematous. His tissues had evidently been
dried before and retained water subsequently, so that he looked and felt better.
The water thus stored on undernutrition was then driven out by increase of the
carbohydrate-free diet, probably especially by the increase of fat, so that by
Dec. 15 weight had fallen to the same level as at entrance. Nevertheless, the
period from Nov. 28 to Dec. 15 must be regarded as one of actual gain of body
substance. There was some perceptible edema when the weight rose above 47
or 48 kg., as on Dec. 22 and Jan. 4. The patient was discharged weighing 45 kg.,
and at least part of the gain over the entrance weight may be regarded as actual
increase of body tissue. This gain should be considered as harmful not only in-
directly, owing to the fact that the patient became too confident from feeling too
well, but also directly, inasmuch as tolerance ought to have been built up in-
stead of weight. Trouble would have resulted later from this condition even if
the patient had remained faithful, and it would have been necessary to make a
radical restriction of his diet. Also the therapeutic possibilities are never so good
after several months of imperfect treatment as at the outset. The cause of the
final disaster was, however, the deep ignorance and lack of education of the
patient and his entire family, who had no conception of the nature of the disease
and were deaf to all advice as soon as the patient felt fairly well. Under such
circumstances a successful outcome was precluded. The favorable side of the
case is that such a degree of well-being and freedom from symptoms was attained
during the 3 months in hospital, while the severity of the case was demonstrated
by the death in comal month after breaking diet.

CASE RECORDS 227

CASE NO. 11.

Female, married, age 55 yrs. Austrian; housewife. Admitted Nov. 9, 1914.

Family History. — Father died at 55, cause unknown. Mother died at 70.
Three brothers and three sisters of patient were healthy; one of them died at 65.
Family are obese. No diabetes or other family disease known.

Past History. — Patient has been strong and weU, though obese. As a young
woman she weighed over 200 pounds, more recently she has considered 183 pounds
her regular weight. No infections, except measles at 16. No sore throats.
She was married at 21 ; four miscarriages; nine children born alive, four of whom
died in infancy. All of those alive are more or less obese.

Present Illness. — 10 years ago she began to notice a bitter taste after eating,
also constipation. 7 years ago a doctor found 7 per cent sugar in the urine, and
by dieting reduced it to 2 per cent. She had followed prescribed diets during
these 7 years, but sugar was never below 2 or 3 per cent. She thinks she has lost
weight chiefly in the last few weeks. She continued to do housework until last
week, when she went into collapse, pale, exhausted, and vomiting blood. Her
physician reported 7 per cent sugar in the urine. He prescribed a diet of noth-
ing but green vegetables for 3 days. Vomiting then made eating impossible.
Patient entered hospital in this condition with extreme weakness, anorexia and
nausea, pain in chest and abdomen, hemoptysis, headache, and dyspnea. The
blood brought up at first is described as being brighter and more abundant than
now.

Physical Examination. — An obese woman with appearance of prostration, face
pale, also extremely cyanosed, cyanosis extending into neck. Moderate constant
dyspnea, a weak frequent cough bringing up sputum either bloody throughout or
streaked with dark blood. Slight jaundice. Lungs: resonance, passing into
dulness at bases, especially posteriorly; breath sounds become bronchial in
character over dull areas and are everywhere rough. Coarse, loud riles every-
where. Heart is enlarged to 16 cm. to left of midsternal line and other signs are
those of mitral regurgitation. Liver is easily palpable, lower border extending
from 2 cm. below umbilicus obliquely into right flank barely above iliac crest.
Pain and tenderness complained of over liver, also pain down left arm. Leg
veins badly varicosed. Examination otherwise negative.

Treatment. — The patient necessarily remained in bed and was treated by the
cardiac service of the hospital with digipuratum for her evident heart failure. The
temperature ranged from 37 to 37.6°, the pulse from 92 to 112. The urine was
strongly acid, with specific gravity 1020 to 1025 and considerable albumin. The
general clinical record is given in Table VHI.

The patient was both weak and drowsy, and the symptoms were evidently due
to a combination of acidosis and heart failure. She took no food on Nov. 9 and
10, nevertheless glycosuria was heavy and weakness seemed to be critical. The
condition had arisen on a diet limited to green vegetables, and the consequences

CASE RECORDS 229

Present Illness. — About 3 years ago abnormal weakness, thirst, and polyuria
appeared. A physician found glycosuria of 7 J per cent. He ordered abstinence
from sugar and pastry. The glycosuria thus diminished to 2 per cent and the
patient felt fairly well, but after 8 months on the same diet the sugar rose to 5i
per cent and weakness returned. He has been unable to work for the past 2
years. For the past week he has been confined to bed because of weakness and
pains in chest and back. There has been cough, especially at night for 2 months
past. No fever and no hemoptysis now, but there was spitting of blood on three
occasions last winter. 18 months ago small ulcers appeared on both feet and
have slowly extended instead of healing; they are painful only when he walks.
He is now nervous and constipated, and teeth have decayed rapidly. He has
continued to lose weight.

Physical Examination. — Patient stiU appears comfortably nourished, with good
color in face. Tonsils slightly enlarged; part of left one is missing. Viscera
no^al to examination. Blood pressure 150 systolic, 95 diastolic. A few patches
of lichen planus on arms. Legs show small varicose veins threatening to ulcerate
at some points. The skin is pigmented and scaly, somewhat eczematous. Sev-
eral small superficial ulcers are present on ankles and feet. No gangrene. Strong
pulse in dorsalis pedis arteries.

Treatment. — Supper was given on the day of admission and then fasting imme-
diately begun. Though glycosuria cleared up in 2 days, the patient being over
weight was given 4 days of absolute fasting followed by 2 alcohol days, then 4
days of green vegetables, then 3 fast-days, and then a diet of moderate undernu-
trition. The superficial infections cleared up promptly. It is a question whether
the trace of glycosuria on Nov. 16 on taking 220 cc. whisky was attributable to
the alcohol. As frequently found at the outset in cases of this type, the food toler-
ance was rather low. Early in Dec. a diet with only 10 gm. or less of carbohy-
drate caused occasional traces of glycosuria, and in the period Dec. 17 to 25 the
attempt to give IS to 40 gm. carbohydrate had to be abandoned because of per-
sistent glycosuria. At the same time the total diet, if the mean body weight be
taken as 80 kg., represented approximately 1 gm. protein and only 25 calories per kg.
On strictly carbohydrate-free diet the patient proved able by Jan. 7 to 8 to take
116 gm. protein and 2600 calories without glycosuria. As he had now been re-
duced by about 11 kg., it was considered advisable in view of his age to allow a
diet of this sort and let him have the benefit of improved living conditions in the
Country and such exercise as he might be able to take. He was therefore dis-
charged on Jan. 9 with this purpose in view.

Subsequent History. — The patient reported at intervals that he was free from
glycosuria, and occasional examinations at the hospital showed absence of sugar,
very slight ferric chloride reaction, and a tendency to gain weight on the pre-
scribed diet. Though he looked well he complained of continual weakness which
made him unable to work. He was very faithful to all instructions, and when
unable because of poverty to obtain the prescribed food he fasted altogether.
He was readmitted to the hospital May 5 for further treatment.

230 CHAPTER m

Second Admission. — The weight at this admission was 82.6 kg.; i.e., about 4
kg. less than at his former admission and about 7 kg. more than at his former
discharge. His food tolerance appeared perceptibly higher, as he was now able
to take a diet of some 120 gm. protein, 50 gm. carbohydrate, and 3000 calories
without glycosuria. On account of the weekly fast-days these figures must be
reduced by ^ to give the actual average intake. Undernutrition was shown by
the fall in weight during stay in hospital. The weight gained outside of hospital
was evidently due to unintentional overstepping of the prescribed quantities. Two
determinations of the blood sugar gave values below 0.15 per cent. A fairly lib-
eral diet was permitted with a view to overcoming the marked weakness, and
exercise within the patient's limited capacity was also encouraged for this pur-
pose. Shortly before his second dismissal he was made accustomed to a diet of
about 100 gm. protein, 50 gm. carbohydrate, and 2500 calories, which repre-
sented a reduction below his known tolerance to allow for unintentional errors.
He was dismissed on June 29 greatly improved in all respects, and was advised
again to take a rest in the country for general hygienic reasons.

Subsequent History. — He reported in person on Sept. 7 with normal urine, feel-
ing able to do moderate work. On Nov. 29 he was seen again; sugar and ferric
chloride reactions were regularly negative and he was making his living at his
usual work. He had gained about 2 kg. since discharge. The same condition
has continued with steady improvement up to the present. He now feels well
constantly and carries on his work without difficulty. His diet satisfies him and
urine remains normal.

Remarks. — This case is a good illustration of a numerous type — diabetes rela-
tively mild but finally bringing the patient to a state of disability. The clearing
up of such a condition generally proves to be neither quick nor easy. The most
important therapeutic measure is the reduction of weight, which, however, may
not have to be carried to the point of emaciation. The patient is benefited
slowly. Unless he has full confidence in the physician, he is likely to abandon
treatment because of the tedious privations of diet and the apparent lack of
benefit. At first he sometimes even looks and feels worse than before.

For the sake of strength, liberties were taken here in the direction of high
feeding which would have meant disaster to a younger patient. More protein
and less fat would doubtless have been better. With a weak patient at such an
age, it was considered that the slight persistent ferric chloride reactions could be
temporarily ignored. The outcome justified the procedure, since the continued
freedom from glycosuria finally brought with it freedom also from ketonuria; but
probably results could have been obtained still more rapidly by taking account
of the acidosis and giving fairly Kberal protein for the sake of strength, very little
fat, in order that the patient might burn off his own fat, and a little carbohydrate
if possible. The salvation of this patient lay in his absolute fidelity. He occa-
sionally imderwent serious privations on account of poverty without once being
tempted to take forbidden food. His age is clearly a factor in the favorable out-

CASE RECORDS 231

come. He shows a tendency to gain tolerance with time. He is able to keep
on a normal level of nutrition, and is not impaired in comfort or usefulness at
present by his diabetes.

CASE NO. 13.

Female, age 11 yrs. American; schoolgirl. Admitted Nov. 14, 1914.

Family History. — Paternal grandfather died of cancer. Antecedents otherwise
healthy. Parents healthy. Five brothers and sisters of patient healthy. No
obesity or other abnormalities.

Past History. — Patient always well, apparently the strongest of the six children.
Whooping-cough and measles before 5, mumps at 6, all mild without sequelae.
Adenoids removed at 6. No sore throats. Regular life, not nervous. Candy
and sweets taken in very limited quantity. Appetite, bowels, sleep, normal.
Highest weight 59 pounds in 1913.

Present Illness. — Sugar was found in urine April 21, 1914, the reason for medical
examination being only slight languor for a very few days preceding. Weight at
this time 57 pounds. She was placed immediately on the usual carbohydrate-free
diet, with gluten bread and occasionally a little ordinary bread, a quart of milk
every day, and a little oatmeal gruel. For the past 6 weeks the quantity of
oatmeal has been increased. Butter and cream were used as liberally as possible
and egg-nogs were given between meals. On this maximum caloric diet she steadily
lost weight. Weight 1 week ago 52J pounds. She was given Fowler's solution
of arsenic sometimes. Sodium bicarbonate was given to the extent of J teaspoon-
ful three times a day for a few days several weeks ago, but was stopped because
it seemed to upset the stomach. For 2 weeks past the increased respiration of the
child had attracted the attention of her attendants, but she still seemed cheerful
and alert. Hair falling out rapidly for past few weeks, ififowels constipated.

Physical Examination. — A fairly normal looking, though thin little girl, lying
quietly in bed with noticeable but not extreme polypnea. Cheeks are flushed
more than normal. Teeth in good condition. Both tonsUs moderately en-
larged. No lymph gland enlargement. Blood pressure 105 systolic, 75 diastolic.
General dryness of skin, most marked on legs. Examination otherwise negative.

Treatment. — The patient received a moderately restricted diet of 1000 calories
for 1 full day in hospital (Nov. 15) when, with 46 gm. protein and 57 gm. carbo-
hydrate in the diet, she excreted 46.8 gm. sugar. Fasting was then begun with
about 20 cc. of whisky daUy. Glycosuria ceased after 3 days of fasting. On
Nov. 19 green vegetables were added to the extent of 3 gm. carbohydrate, and
4 gm. on Dec. 20 and 21. The glycosuria of Dec. 20 seemed to be
clearly due to this quantity of carbohydrate, since violations of diet were posi-
tively excluded. It cleared up spontaneously the next day, as this sort of glyco-
suria often does. On Nov. 22, 40 gm. sugar-free caramel were given'' in doses of

* 40 gm. caramel given on Dec. 29 not shown in graphic chart.

232 CHAPTER ni

5 to 15 gm. throughout the day. No glycosuria resulted, though the tolerance
was so low. As the patient needed a diet to conserve strength, the food on Nov.
23 consisted of 3 eggs and 14 gm. alcohol. Nov. 24, SO gm. steak were added.
Nov. 25, the meat was increased to 100 gm. On the following days fat was added
in the form of bacon and oUve oil, so that on Nov. 29 to 30 the diet was approxi-
mately 46 gm. protein and 1100 calories, or 2 gm. protein and 50 calories per kg.
for a weight of 22 kg. This allowance, abundant even for a child, caused glyco-
suria. It was checked by a sharp reduction of diet. The glycosuria shown at
intervals during the next 3 months was always slight, generally no more than
faint traces in certain periods of the day, often indistinguishable if the tests were
performed upon the mixed 24 hour urine, and sometimes connected with urinary
calculi or with the .use of vegetables.

! The condition was compUcated by the former trouble. In Dec, the patient
complained of pain in back and bladder region, and painful urination. Later
^loody urine was passed and some small clots. On Dec. 21, examination was
piade by a urologist, and the next day x-ray plates were taken. Nothing posi-
tive was found, but on subsequent days a few tiny calculi were passed. Several
milder attacks of this character occurred subsequently, and seemed in each
instance to aggravate slightly the tendency to glycosuria.

The diet was carbohydrate-free in the strictest sense, inasmuch as this pa-
tient could not tolerate thrice cooked vegetables, but showed glycosuria when
attempts were made to use them. For example, on Jan. 23, after 2 weeks of
complete sugar-freedom, 250 gm. thrice cooked celery were added to the diet and
glycosuria appeared. The vegetables were stopped and the diet reduced, and the
glycosuria ended. Then, on Jan. 25, 100 gm. each of thrice cooked celery, as-
paragus, and Brussels sprouts were added, and on Jan. 26, 100 gm. each of the
asparagus and Brussels sprouts without celery. The sUght glycosuria was checked
by a fast-day with 11 gm. alcohol on Jan. 28. On Jan. 29 the attempt to use 300
gm. thrice cooked vegetables was resumed, and it was again necessary to stop
glycosuria by a fast-day on Feb. 1. Traces of glycosuria then reappeared when
diet was resumed without the vegetables, indicating that some injury had been
done, but a glance at the graphic chart will show that the patient soon was able
to take a higher diet without glycosuria when all vegetables were omitted (e.g.
45 gm. protein and 670 calories on Jan. 23, with vegetables, with glycosuria;
45 gm. protein and 850 calories on Feb. 26, without vegetables, without glyco-
suria). The abiUty to tolerate higher diets during the first half of Apr. (up to
63 gm. protein and over 1900 calories on Apr. 17) must be attributed to a gradual
gain in tolerance. Improvement was finally indicated by the ability to remain
sugar-free on decidedly higher diets.

As the home conditions were good and the parents absolutely trustworthy,
it was considered feasible to let the patient take a vacation at this critical period
in her treatment, for relief from the abnormal hospital environment. She was
therefore dismissed on June 5 with the idea that she might be able to spend
perhaps 2 or 3 weeks at home.

CASE RECORDS 233

Acidosis. — This was first measured by analyses of the acetone bodies and am-
monia. At the outset, the characteristics of acidosis without alkali treatment
were seen in the moderate ketonuria and high ammonia. Beginning Nov. IS,
20 gm. each of sodium bicarbonate and calcium carbonate were given daUy. The
sodium bicarbonate was stopped on Nov. 25, but the calcium carbonate continued
until Dec. 4. The beginning of protein-fat diet on Nov. 23 caused a rise of the
ammonia from 0.45 gm. up to 0.98 gm. notwithstanding the use of alkali. The
stopping of sodium bicarbonate on Nov. 25 brought an immediate jump of the
ammonia up to 1.8 gm. Seemingly the continuance of 20 gn^ calcium carbonate
daily did not serve to prevent this high ammonia. Also as usual the bicarbonate
apparently served to keep up the ferric chloride reaction, for this quickly became
pale after bicarbonate was discontinued. It is seen that the ammonia gradually
fell to a level which may probably be considered normal on protein-fat diet, also
the ferric chloride reaction became negative, not in consequence of the use of
carbohydrate which was formerly considered necessary to combat diabetic acidosis,
but solely by reason of the gradual undernutrition. Determinations of the blood
alkalinity were begun on Jan. 29 and showed a subnormal level of 47 vol. per cent.
On Feb. 6, the level was still lower, viz. 41 per cent, and on Feb. 13 a still lower
value of 39.5 per cent was found. The condition took care of itself without the-
use of any alkali, and the combining power of the plasma remained at or above 50
vol. per cent until the close of Apr. Up to this point the ammonia excretion and
the ferric chloride reaction proved the more sensitive indicators. It wiU be noted that
the ammonia curve touched its lowest point at practically the identical time with the
lowest point of the weight curve, namely the middle of Feb., and the ferric
chloride reaction was negative at the same time. With the increase of protein-
fat diet came a gradual and practically parallel rise of the ammonia and weight
curves; also ferric chloride reactions appeared and increased correspondingly.
In the fasting periods, Apr. 29 to May 1 and May 16 to 18, the plasma bicarbon-
ate gave indications of acidosis not revealed by the other tests. The ferric
chloride reaction was not perceptibly altered, and the ammonia excretion distinctly
fell in both fasts. The lowering of the plasma bicarbonate may serve as a delicate
indicator under such circumstances, since it sometimes falls to a point giving
warning of dangerous acidosis in fasting, and at this point clinical symptoms
correspond. The degree of the fall was not dangerous here, and chnical symp-
toms were absent. In the period May 15 to 19 inclusive, 5 gm. sodium bicarbon-
ate were given daily with 30 cc. whisky, to test whether this combination of alkali
and alcohol had any effect upon the fasting acidosis. The result showed only a
slight difference as compared with the period Apr. 29 to May 1. The ferric chlor-
ide reaction was unchanged, the ammonia was a bare trifle lower and the plasma
bicarbonate a trifle higher, but the difference was within the range of accidental
variation. Carbohydrate from 10 to 30 gm. in the forepart of May faUed to
clear up the ferric chloride reaction, which also persisted through fasting, but be-
came negative on the fast-day of May 23 and remained so until the diet was m--

234 CHAPTER ni

creased on June 2. Here it is evident that simple increase of fat produced this
reaction.

Blood Sugar. — ^This was determined only occasionally in the period Apr. 16 to
May 21, samples being taken in the morning before breakfast. The first two de-
terminations were approximately 0.15 per cent. This was considered too high,
and the period of almost 4 days of fasting (Apr. 28 to May 1 inclusive) was im-
posed for the purpose of bringing it down. It was thus made and kept normal
(as far as fasting values were concerned) until the increase of carbohydrate
to 30 gm. on May 14 brought glycosuria with hyperglycemia of 0.18 per cent the
fofllowing morning. A similar fasting period then succeeded in bringing it down
almost to normal. The alkali given as above described during this phase did
not serve to bring the blood sugar lower. Hyperglycemia again resulted from the
subsequent diet containing 10 gm. carbohydrate, and this was one of the reasons
for omitting this carbohydrate.

Weight and Nutrition. — In the period Nov. 16 to 22 inclusive, with practically
no nitrogen intake, there was a loss of 20.55 gm. nitrogen in the urine. In the
first 3 months in hospital, undernutrition is indicated by the fall in weight from
21,2 kg. on Nov. 16 to 16.8 kg. on Feb. 16, being a loss of 4.4 kg., or about one-
fifth of the weight at entrance. The diet of this period, after the brief excess in
Nov., was in the neighborhood of 45 gm. protein and 700 calories, or a little
over 1 gm. protein and 35 calories per kg. of weight, but the rather frequent
days of fasting or low diet reduced the average materially below this figure. Gain
in weight began with the increase of diet in the latter part of Feb. In conse-
quence, both sugar and ferric chloride reactions were present early in Mar. There-
after the ferric chloride tests and the unduly high ammonia were the chief indi-
cations of improper diet.

In the early half of Apr. the ration was generally 63 gm. protein and 1700 to
1900 calories (about 3.3 gm. protein and 90 to 100 calories per kg.) with fast-
days somewhat reducing this average. On Apr. 19 a better balanced diet was
instituted, consisting of 49 gm. protein, 5 gm. carbohydrate, and 1322 calories,
increased by May 14 to 57 gm. protein, 30 gm. carbohydrate, and 1593 calories.
Distinct glycosuria resulted at this time. After a period of fasting, a decidedly
lower diet was given beginning May 19. Though the ability had been shown to
tolerate 10 gm. carbohydrate during this time, it was considered safer to boil out
carbohydrate in the diet at home. Accordingly the diet prescribed at discharge
consisted of 68.5 gm. protein, 250 gm. thrice cooked vegetables, and 1500 to 1600
calories (about 3.5 gm. protein and 80 calories per kg., reduced by weekly fast-
days to about 3 gm. protein and 70 calories average).

At discharge the weight was 19 kg.; i.e., 2.2 kg. less than at admission. The
half year of treatment thus represented imdernutrition to this extent. There
was no gain, and if anything a slight loss of strength, also no growth in stature.
The child was thoroughly cheerful, and able to be about and keep herself amused
all day.

CASE RECORDS 235

Subsequent History.— The progress at home was better than expected. Reports
and samples of urine showed continued absence of both sugar and ferric chloride
reactions. On July 1 the addition of 5 gm. carbohydrate was tolerated. On Aug.
1 an increase to 10 gm. carbohydrate brought a trace of glycosuria. The allow-
ance of S gm. continued to be tolerated, and the child gained also in weight and
appearance. Oct. 3, occasional traces of sugar were reported, and on advice the
patient returned to the hospital on Oct. IS for further treatment, having suc-
ceeded in remaining in good condition at home for 4 months instead of the few
weeks anticipated.

Second Admission. — The patient returned weighing 20.8 kg.; i.e., with a gain of
1.9 kg. over her weight at discharge and a loss of O.S kg. from her weight on first
admission. Her appearance and actions indicated a decided gain in vigor.
On the same carbohydrate-free diet prescribed at discharge she showed moderate
glycosuria, marked hyperglycemia (plasma sugar 0.25 per cent), a well marked
ferric chloride reaction, and a slightly subnormal plasma alkalinity. Accordingly
fasting was begun on Oct. 17, and sugar-freedom resulted within the first 24 hours.
After an additional 24 hours of fasting, a carbohydrate tolerance test with green
vegetables was begun for the usual diagnostic and therapeutic reasons. Beginning
as usual with 10 gm. carbohydrate on Oct. 19, an increase of 10 gm. carbohydrate
was made daily, with the result that 60 gm. carbohydrate was established as the
tolerance. The traces of glycosuria on Oct. 25 and 26 exemplified the false limit
sometimes encountered in such tests, when there is a trivial excretion on a cer-
tain intake, which disappears after this intake is continued or increased. This
affords no comparison with the tolerance on the previous admission, because no
test was then made with carbohydrate in the absence of other foods. In con-
sequence of this undernutrition with carbohydrate to the point of tolerance, the
blood sugar as determined mornings before breakfast fell to normal, the ferric
chloride reaction became negative, and the plasma bicarbonate rose to normal.
After a fast-day on Oct. 31 to clear up the glycosuria resulting from the carbo-
hydrate test, a diet was begun which was better planned than on the previous
admission; namely, 50 gm. protein, 10 gm. carbohydrate, and 1000 calories. Be-
cause of glycosuria it was necessary on Nov. 8 to reduce the carbohydrate, and
after Nov. 15 it was regularly 5 gm. For a body weight of 20 kg., this diet rep-
resented 2.5 gm. protein and 50 calories per kg. The weekly fast-days reduced
this to an average of approximately 2.14 gm. protein and 43 calories per kg.
The general well-being was definitely improved by this lower diet and the intro-
duction of carbohydrate, as compared with what was observed on the previous
admission. The carbon dioxide capacity of the plasma, which had been as low
as 45 per cent, rose to 55 per cent without the use of alkali. The blood sugar,
which had risen with the appearance of glycosuria at the close of the carbohydrate
test, continued unduly high, but remained below 0.2 per cent and gradually fell
below 0.15 per cent. The patient was dismissed on Dec. 14 weighing 19.3 kg.;
i.e., 1.5 kg. below her weight at this admission, and 0.4 kg. above her weight at
the former discharge.

236 CHAPTER III

Exercise. — During the former time in hospital the chUd was kept at rest, partly
because of weakness. This time she was given regular exercise to the limit of
comfortable endurance. No detailed studies were made, but it was evident that
no striking increase in tolerance was produced in such a severe case of diabetes.
Existing glycosuria was not cleared up by exercise, also it was not possible to
raise the carbohydrate ration higher with exercise than without. On the other
hand, the exercise certainly did no harm; it may have had a share in the gradual
reduction of the hyperglycertua; and it unmistakably improved the strength, well-
being, and enjoyment of the child. The exercise was mostly in the form of ball-
tossing, walking, roUer-skating, and other play.

Subsequent History. — The patient remained sugar-free at home, and took up
some school work in Feb., 1916. Increase of carbohydrate to 10 gm. was tolerated
without glycosuria. In May she caught cold, showed traces of sugar almost con-
stantly, and lost IJ pounds in 2 weeks by reason of the undernutrition necessary
to keep down glycosuria. Her former tolerance returned with recovery ftom the
cold. Glycosuria remained absent practically continuously until July, when
persistent traces of sugar made it advisable for the patient to return to the
hospital.

Third Admission. — ^July 7, 1916. The weight at this admission was 20 kg.;
i.e., 0.7 kg. more than at discharge 6i months previously. The height was 132
cm. Under regular diet, July 7 to 10 inclusive, there were stiU marked sugar and
ferric chloride reactions. The plasma sugar on July 11 was again 0.25 per cent,
and a rigid period of undernutrition, including fasting and a carbohydrate test,
was therefore instituted. The tolerance for carbohydrate was identical with
that in the previous October. The treatment reduced the blood sugar to 0.13
per cent, but it rose to 0.22 per cent on resumption of the previous diet. The
weight was thereby reduced to 17.2 kg., which was lower by 4 kg. than at the
first admission. The patient was still cheerful and active, and returned home in
this condition.

Subsequent History. — In Aug., on account of shght glycosuria, carbohydrate was
omitted from the diet. The disturbance seemed to be associated with kidigestion.
Otherwise the sugar and ferric chloride reactions remained negative. The patient
attended school half of each day, and took automobile rides and other recreation.
In Oct. bloody urine reappeared and two small calculi were passed. This trouble
seemed to affect her diabetes very badly, and for this reason she reentered the
hospital Oct. 24, 1916.

Fourth Admission. — Weight 19.3 kg. Appearance thinner, paler, and weaker
than previously. The change for the worse is said to date from the attack of cal-
culi. The urine by this time was free from blood, and physical and x-ray examina-
tions were negative. The patient was made sugar-free by 2 days of fasting, then
given green vegetables representing S gm. carbohydrate the first day, increasing
by 5 gm., daily up to SO gm., which was the Umit of tolerance; i.e., a loss of 10 gm.
as compared with previous tests. She was then placed on a diet of 30 gm. pro-

CASE EECOIOJS 237

tein, 20 gm. carbohydrate, and 600 calories, and was encouraged to exercise
within the hmits of her strength. A routine fast-day was given once a week.
Because the strength remained low, this diet was changed on Nov. 23 by dimin-
ishing the carbohydrate to 10 gm. and increasing the protein to 40 gm. For the
same reason on Dec. 4 carbohydrate was omitted from the diet and the protein
increased to 45 gm. The patient at this time took walks of 8 blocks without
weariness, and was outdoors much of each day. Blaud's pills were given because
of anemia. The patient remained in hospital until Feb. 1, 1917, when she was
dismissed on a carbohydrate-free diet of 40 gm. protein and 700 calories, weigh-
ing 17 kg.; i.e., 1.2 kg. less than at this admission, and 4.3 kg. less than at her
original admission in Nov., 1914.

Acidosis. — The ferric chloride reaction remained constantly negative. Traces
of acetone were constantly present, as must be expected on such a diet. There
was a daily excretion of 0.18 to 0.64 gm. ammonia nitrogen, the output being
lower in the earUer period of lower calories with carbohydrate in the diet. Symp-
toms of acidosis were entirely absent, and the carbon dioxide capacity of the
plasma was 65.3 per cent at dismissal.

Blood Sugar. — ^Hyperglycemia was continuous, in general close to the threshold
of glycosuria as shown in the charts of former periods. The blood sugar at dis-
missal was 0.2 per cent.

Subsequent History. — The condition continued the same at home as in hospital,
the patient remaining very thin but bright and active. In Mar. a "green day"
was advised in the middle of each week to break the monotony of the diet, di-
minish the total calories, and introduce carbohydrate. Traces of sugar appeared
only occasionally and at first cleared up with the routine fast-days. The usual
slow downward progress occurred under these circumstances, but owing to the
■derangement of the hospital organization by the military emergency, the patient
was not required to return for treatment until Oct. 10, 1917. By this time she
had been seriously weakened by the frequent fasting necessary to control glyco-
suria, though she was still up and about.

Fifth Admission.— Oct. 10, 1917. Weight 16.6 kg. The patient had stood the
trip from Massachusetts very well. One day of fasting cleared up the shght
existing glycosuria. On the second fast-day the plasma sugar was 0.098 per cent,
CO2 capacity 55 per cent. On the evening of the second day the fast was broken
with 5 gm. carbohydrate in the form of a salad. The urine was continuously nega-
tive for both ferric chloride and nitroprusside reactions, and the nitroprusside test
of the plasma was likewise negative. Carbohydrate was increased by 5 gm. daily
without glycosuria. Oct. 16, breakfast was taken as usual, but collapse occurred
about 10 a. m. and death about noon, preceded by slight tetanoid convulsions.
The urine at this time was still normal. The blood showed hemoglobin 22 per
cent, plasma sugar 0.02 per cent, CO2 capacity 69.7 per cent. The employment
of the carbohydrate test was a mistake, for though the child was up and about
until the day before death, the low blood sugar on the second fast-day was a

238 CHAPTER in

pkin indication of exhaustion, and protein should have been fed instead of car-
bohydrate. Nothing, however, could long have prevented the fatal termination
under the circumstances at this time.

Remarks.— The patient presented juvenile diabetes of great severity. Within
about half a year she had come close to coma and had lost carbohydrate tolerance
almost completely. It is evident that the assimilation had already fallen too low
to support growth, owing to lack of treatment in the earlier stage. Under treat-
ment she was then kept alive and in tolerable comfort and activity for nearly 3
years. Two aspects of the progress may be noted.

On the one hand, no special tendency to recovery of assimilative function has
been manifest. During the first period of over 6 months in hospital, it is true
that the food tolerance decidedly improved, but this result was merely the accom-
paniment of some 2 kg. loss of weight and does not necessarily indicate any
change in the fundamental assimilative power. At the second admission the
weight was up almost to the original figure, but other conditions were different.
Active diabetes was present again at this admission. The carbohydrate tolerance-
was tested with exclusion of other foods. Thereafter carbohydrate could be in-
cluded in the diet, but this was on a lower ration than during the first admission.
Real improvement in assimilation would have meant that the child could grow in
weight and stature; on the contrary, the third and fourth admissions represented
further loss of weight. The carbohydrate tolerance in July, 1916, was the same
as in Oct., 1915, but as the latter test was at a lower body weight, the result may
be interpreted as actual downward progress.

On the other hand, the record furnishes evidence against the "spontaneous"
character of such downward progress. Hyperglycemia was almost continuous,,
and glycosuria and ketonuria recurred rather frequently throughout the entire 3
years. A partially depancreatized dog under similar conditions would have gone
into hopeless diabetes much sooner. Any inherent downward tendency should
have been perceptible in this type of case in this length of time. The slow change
observed is abundantly explainable by the prolonged slight overstrain of the
weakened function.

CASE NO. 14.

Male, married, age 51 yrs. American; optician. Admitted Nov. 16, 1914.

Family History.— Fkthei died of typhoid at 28, mother of heart trouble and'
dropsy at 55. Two sisters living and well. Patient has been married 23 years;
one child dead, one living and well. Tuberculosis, cancer, syphilis, diabetes, and
other family diseases denied.

Past History.— Kenlthy life. Scarlet fever in childhood. Occasional sore
throats. Gonorrhea twice. Syphilis denied by name and symptoms. In Apr.,
1914, he was confined to bed with so called dry pleurisy and had cough and
slightly blood-tinged expectoration for 3 or 4 weeks. Constipation, slight indi-
gestion, moderate or poor appetite. Alcohol used rather freely but not to-
drunkenness. Moderate tobacco.

CASE RECORDS 239

Present Illness. — 7 years ago patient states that he strained himself lifting a
trunk. He had pain in the back for several months, therefore had his urine
examined and sugar was found. He claims never to have had any of the typical
diabetic symptoms. He now complains of indefinite neuritic pains in back and
legs. His best weight was 140 pounds 6 years ago; now 112. A few days after
• admission the patient's wife volunteered the information that he had undertaken
a number of different treatments for his diabetes at different times, but had never
adhered to any prescribed diet for even a brief time.

Physical Examination. — ^A fairly developed, poorly nourished man. Teeth
mostly absent, little decay in those remaining, slight pyorrhea. Throat con-
gested but tonsils not visibly enlarged. Cervical, axiUary, epitrochlear, and in-
guinal glands slightly enlarged. Reflexes very active. Blood pressure 100 sys-
tolic, 70 diastolic.

Treatment. — ^After 2 days of observation on a low protein-fat diet, fasting was
begun on Nov. 18. On Nov. 20 to 22 he received 27 to 35 gm. alcohol. This
S day fast greatly diminished but did not quite abolish glycosuria. The ferric
chloride reaction, which was negative on the day of admission, became strongly
positive on the carbohydrate-free diet and on fasting. The weight fell sharply
from 50.6 to 47.6 kg. On Nov. 23, 300 gm. thrice cooked vegetables were given
to appease the patient, who was discontented. This program continued up to
and including Dec. 1. As such vegetables are reckoned as having too little food
value to count, the treatment represents 2 weeks of practically continuous fasting
except for the alcohol mentioned. The continuance of glycosuria aroused sus-
picion. Accordingly the patient was removed from the ward to a private room,
and glycosuria abruptly ceased (Nov. 26). He was then returned to the ward,
and was sufficiently impressed by his sugar-freedom that he followed diet with
some degree of fidelity thereafter, though some of the traces of glycosuria are
doubtless to be attributed to slight violations. A low diet was begun, and it was
found that the tolerance was actually very low, the smallest quantity of carbo-
hydrate bringing on glycosuria, while even on protein-fat diet traces of sugar were
frequent, apart from any steaUng of food. The patient was discontented and
unreliable, and the irregular shifts of diet resulted largely from attempts to please
him. The general outcome of the treatment was to reduce his weight from the
original 50.6 kg. to 44.8 kg., with the result that glycosuria was absent on a car-
bohydrate-free diet of 53 gm. protein and over 2200 calories, but a well marked
ferric chloride reaction persisted. Thorough treatment was not carried out
because the patient had never been seriously iU and would not have endured
rigorous measures. Accordingly he was allowed to go on Mar. 2, with his con-
dition improved but by no means satisfactory, on a prescribed diet of about 50
gm. protein and 1500 to 1750 calories.

Subsequent History. — On Apr. 1, patient returned to the hospital reporting that
he had followed diet, had remained permanently sugar-free, had gained 6 pounds,
and was enjoying greatly improved health. His appearance conformed to the

240 CHAPTER m

statement, but a sample of urine showed a trace of sugar. Information from other
quarters indicated that he had not adhered strictly to his diet. On Apr. 9, he
again reported and his urine was found sugar-free. On May 20, he reported
showing a slight glycosuria, and information was given by his family that he had
departed somewhat from his diet. Since then nothing has been heard of him.

Remarks. — ^The case illustrates diabetes of long standing, apparently doing the-
individual little harm but bringing progressive injury in the course of years,
and undoubtedly destined not only to impair comfort and usefulness, but also
to shorten life. As frequently found in such cases, a normal state of the urine is
very diflBicult to establish and maintain, and rigorous restriction of food and re-
duction of weight for a number of months are necessary for a satisfactory re-
sult. Such patients are often not convinced that these measures are necessary,
especially since they feel decidedly worse during the period of rigorous restric-
tion. FideUty brings ultimate reward in comfort and longevity. On the other
hand, the penalty of carelessness is often slow in appearing, and accordingly the
lesson is often learned too late.

CASE NO. 15.

Male, married, age 42 yrs. Scotch; bookkeeper. Admitted Nov. 16, 1914.

Family History. — ^Entirely negative as far as can be learned from wife.

Past History. — Healthy life.

Present Illness. — Patient is known to have had diabetes for about 2 y^ars past,
with practically no symptoms except some loss of weight and strength. He has
continued at his work until the present week. He was not supposed to be seri-
ously unwell until last evening, when a doctor was sent for hurriedly and found
him in coma to such a degree that he could not be roused enough to recognize
persons. The physician cleared out considerable feces by the use of cathartics
and enemas and gave a few small doses of sodium bicarbonate by mouth. This
morning the patient was stiU in coma, but was apparently a little more easily
roused.

Physical Examination. — Fairly good muscular development along with moderate
emaciation. Routine physical examination negative. Kjiee jerks absent. The
usual picture of coma, except that h3Tjerpnea is not striking. Respiration is
fuU, but quiet. When forcibly roused the patient regains consciousness suffi-
ciently to utter words in drunken meaningless fashion, but not to recognize his -
wife or doctor. With some difficulty he can be induced to swallow medicine and
to pass urine.

Treatment. — ^This was the first case of actual coma received, and the orthodox
treatment was attempted, with an intravenous infusion of 1 liter of 4 per cent
sodium bicarbonate solution prepared without heat and sterilized by filtration
through porcelain. The injection was apparently well borne; pulse, respiration,
and consciousness showed no appreciable, change during the period of injection,
which lasted about an hour. IS cc. whisky were given hourly. The patient

CASE RECORDS 241

was received at 5 :30 p.m. The infusion was finished at 7 p. m., and death occurred
suddenly and without warning at 7:50 p.m.

The following laboratory data may be noted. Heavy glycosuria and ketonuria
both before and after bicarbonate infusion, not determined quantitatively because
of loss of considerable urine. Blood sugar 0.316 per cent. Sodium chloride in
serum 6.11 gm. per liter. Sodium chloride in urine 0.2 gm. per hter before in-
fusion. The urine passed after bicarbonate infusion was pale and abundant as
before, but contained no chlorides.

Remarks. — Though few patients ever come out of actual coma, this man was
one who appeared to have a fighting chance. At that time it was hoped that
the alkali in the customary dosage would reinforce whatever benefit he might
derive from fasting. Without the intravenous alkali he might have had a chance.
Later experience makes it seem probable that when a patient in this condition
receives an injection of alkali in this manner and quantity, no immediate harm
and sometimes an apparent benefit is perceptible, but sudden death is likely to
occur within a few hours.

CASE NO. 16.

Female, married, age 47 yrs. American; housewife. Admitted Nov. 17,
1914.

Family History. — Father died of cancer at 61. Mother had diabetes; died of
sepsis from varicose veins in legs at 74. Brother aged 61 has mild diabetes.
Patient's husband died 20 years ago, aged 34, of some condition resulting from
alcoholic excess. Three chUdren; the two older living and weU; the youngest
was mentally deficient and died last July at the age of 20, after having been
treated from childhood for syphilis.

Past History.— Healthy childhood. Measles and mumps when very young.
Chlorosis before marriage. Married at 20; two children within a year of each
other; no miscarriages. Third child, born 4 years after second, showed syphilis,
and patient after its birth had sore on tongue and hair fell out. There was also
a genital chancre. Symptoms cleared up after 1 month of treatment with blue
ointment. No further symptoms or treatment. Regular habits. No excess in
alcohol, tea, coffee, or sweets. Never nervous until recent years. Ordinary
weight 180 pounds.

Present Illness. — 5 years ago patient began to feel weak and lost 20 pounds in
weight. Physician found glycosuria of 4§ per cent. She has dieted more or less
since then, but has been sugar-free only occasionally, never more than a few
months. Lowest weight 143 pounds last August. Menstruation stopped 6
months ago. Especially for the past 3 weeks she has felt weak and miserable and
been troubled with thirst, headache, pains in knees, cold feet, pruritus vulvae,
failing vision, and loosening and falling out of teeth.

Physical Examination. — Height 158 cm. A rather obese woman, looking
strong but nervous. Several teeth missing; others loose. Throat normal. No

242 CHAPTER m

palpable lymph node enlargement. Murmur of mitral regurgitation. Area of
cardiac dulness slightly enlarged. Arteries hardened. Blood pressure 225
systolic, 110 diastolic. Albumin and casts in urine. Knee and Achilles jerks
slight. . A few small copper colored scars on legs. Uterus sUghtly retroverted.
Right Fallopian tube slightly tender. Blood shows strong Wassermann reac-
tion. In addition to diabetes, there was a diagnosis of chronic mitral insuffi-
ciency, chronic interstitial nephritis, latent syphilis, arteriosclerosis, and cystitis.
Twice during hospital sojourn the patient complained of dizziness and fainted,
and was treated for short periods with digipuratum. Syphilis was not treated
at this time, and the effect of dietetic treatment of the diabetes was tested alone.

Treatment. — ^As shown in graphic chart, the patient fasted Nov. 18 to 20 inclu-
sive, receiving respectively 45 and 75 cc. whisky on the last 2 days. On Nov.
21 she received cauliflower, celery, and asparagus to the amount of 17.5 gm. car-
bohydrate. As the primary object was to reduce weight, 3 more days of practi-
cal fasting (Nov. 22 to 24) followed, the only food being 800 gm. thrice cooked
vegetables daily. On Nov. 25, one egg was added. This diet was rapidly in-
creased to about 1100 calories on Dec. 6 and 2300 calories on Dec. 19. AU at-
tempts to introduce even small quantities of carbohydrate led to glycosuria, and,
as shown in graphic chart, numerous periods of low diet or fasting were employed
to diminish the weight further. She was finally (Jan. 27 to 29) placed on a car-
bohydrate-free diet of 66 gm. protein and 1400 calories. This, for her weight of
54.5 kg. at that time, was about 1.2 gm. protein and 26 calories per kg. The pa-
tient insisted that this diet with addition of 500 gm. thrice boiled vegetables satis-
fied her appetite perfectly, and as she was very eager to be home and had received
the necessary instruction, she was allowed to leave in this condition. All sub-
jective symptoms had disappeared and she felt fuUy strong and well.

^Subsequent History. — The progress continued to be favorable at home, and in
Feb. the diet was increased by 400 calories of bacon. Sugar remained constantly
absent and the ferric chloride diminished to a trace. It became entirely negative
about June 1. The plasma sugar on June 1 was 0.114 per cent. The weight
was 54.5 kg. By Oct. 5, the patient had gradually increased the quantity of food,
the weight had risen to 59.8 kg., and the plasma sugar to 0.196 per cent, with nega-
tive sugar and ferric chloride reactions in urine. Blood pressure 250 systolic, 160
diastolic. She was advised to avoid gaining weight. Excellent subjective
health and normal urine continued, and 1 year after discharge she reentered the
hospital by request for examination and advice.

Second Admission. — ^Jan. 31, 1916. The weight at this time was 63 kg.; namely,
8.6 kg. above that on dismissal and 2 kg. below that at former admission. The
urine showed negative sugar but a trace of ferric chloride reaction. Feb. 2 a fast-
day was given, and then a carbohydrate tolerance test, begiiming with 10 gm.
carbohydrate and increasing by 10 gm. daily vmtil by Feb. 23 to 25 the limit of
tolerance was reached with 220 gm. carbohydrate. After a fast-day on Feb. 27
to clear up the slight glycosuria, a diet was instituted of 90 gm. protein, 20 gm.

CASE RECORDS 243

carbohydrate, and 2000 calories (1.5 gm. protein and 34 calories per kg., reduced
by weekly fast-days to about 1.3 gm. protein and 30 calories average). On this
diet the patient was dismissed, weighing 59.5 kg.

Acidosis. — The patient was admitted originally with chronic glycosuria and
negative ferric chloride reaction. The result of fasting, notwithstanding 75 cc.
whisky on Nov. 20 and 17.5 gm. carbohydrate on Nov. 21, was the development
of a ferric chloride reaction. This persisted during most of the first stay in hos-
pital. It could doubtless have been cleared up by repeated periods of carbohy-
drate (without other food) to the limit of tolerance. But the tolerance at that time
was low, and for a patient with such inherently mild diabetes at a fairly advanced
age, it was considered sufficient to pursue a treatment of progressive undernu-
trition, knowing that the trivial acidosis would disappear as soon as the tolerance
was built up. This expectation was fulfilled in the period after leaving hospital.
With rise of weight, traces of ketonuria had returned at the time of second admis-
sion; these were readily cleared up by the carbohydrate tolerance test, and by
increasing carbohydrate in the diet. Since then ketonuria has remained per-
manently absent. As shown in the second graphic chart, the plasma bicarbon-
ate was slightly below the lower normal limit; but the tendency was upward, and
no alkali was employed.

Blood Sugar. — ^This was easily kept at normal level by regulation of body weight.
On this point the patient might be brought into line with the type formerly called
"fat sensitive." It wiU be observed in the second graphic chart that hyper-
glycemia was present on Feb. 2 after a diet of 2350 calories made up chiefly of
fat with very little carbohydrate. This elevated blood sugar is seen to have fallen
to normal subsequently when the carbohydrate was decidedly increased and the
total calories diminished. Though nephritis and arteriosclerosis were present
with hypertension, there was no tendency to a stubbornly high blood sugar.

Subsequent History. — The patient has reported at intervals to date, feeling en-
tirely healthy and leading a fully normal life with faithful attention to diet.
Weight June 19, 1917, 63.6 kg. This increase of weight has been borne with&ut
any glycosuria. The high blood pressure remains, also the albumin and casts in
urine. Lately she has complied with advice given several times before and has
taken a few salvarsan injections, without alteration of clinical findings. The
cardiorenal symptoms are perceptibly increasing, and death from this cause is to
be expected.

Remarks. — Two possible etiologic factors are here present, one heredity, the
other syphilis. Notwithstanding these, and even in absence of syphilitic treat-
ment, the entire tendency under suitable dietetic treatment through nearly 3
years of observation has been upward and not downward. This success has been
attained by regulation of the total caloric ration and body weight. It is practi-
cally certain that a progressive downward tendency could have been observed if
the weight had been built up with high calory, carbohydrate-poor diet. Such a
tendency is distinctly indicated by the findings at several times when weight was

244 CHAPTER ni

gained. Another interesting feature is that in Apr., 3 months after the first
dismissal, the patient had an acute otitis media and underwent paracentesis under
ether, but showed no sugar throughout this illness. From present indications the
prognosis in such a case is satisfactory from the standpoint of diabetes, and life
and comfort are apparently limited only by the other diseased conditions present.

CASE NO. 17.

Female, married, age 69 yrs. Russian Jew; housewife. Admitted Nov. 17)
1914.

Family History. — Indefinite on account of ignorance. Most of family seemingly
lived to considerable age, and patient knows of no family diseases. Patient has
been married 43 years. Seven children; four died in infancy, cause unknown; one
is in a pubhc institution with diagnosis of dementia praecox; the other two are
middle-aged and well.

Past History. — Measles in childhood. Came to New York from Russia 26
years ago. Hygienic surroundings bad. No diseases of consequence, except em-
pyema with pneumonia 20 years ago. This was drained, and two subsequent
operations were necessary before the sinus was closed a year later. She has had
no s)rmptoms pointing to tuberculosis. She has long complained of indigestion,
gas, and constipation. 6 years ago she underwent an operation for uterine pro-
lapse; there was a laparotomy and removal of some sort of tumor, concerning
which she knows nothing except that it was not cancer.

Present Illness. — ^Time,of onset unknown, but during the past 7 years her weight
has steadily diminished from 180 down to 108 pounds. Polyphagia never marked,
and polydipsia noticed only in the past few days. 6 weeks ago pain began in
the right foot with some discoloration around the great toe and heel. Local
measures did not benefit it. A physician suspected gangrene immediately upon
seeing it and found heavy glycosuria present. This was the first diagnosis of
diabetes. She is now unable to walk because of pain in this foot, which is also
painful when she remains in bed.

Physical Examination. — Patient fairly nourished, lying in bed with quiet respira-
tion, but with decided sweet odor of breath. Dirt and pedicuH noticeable. Nu-
merous teeth missing or carious. No gland enlargements except in groins. A
few bronchitic rales. Heart sKghtly enlarged. Blood pressure 215 systolic, 150
diastoUc. Depressed scars on left thigh, pigmented scars on right shin. Swell-
ing, reddish blue discoloration and tenderness of great toe and over and under
first and second tarsometatarsal joints of right foot. The heel of this foot is
painful, the skin is Hfted up and evidently has fluid under it.

Treatment. — Patient received supper on the day of admission, consisting of 25
gm. AkoU biscuit, 10 gm. butter, and a cup of coffee. The next day she fasted
with 35 cc. whisky, and became sugar-free in 24 hours. The ensuing days were
also fast-days, with whisky up to 90 cc. On Nov. 23, one egg and 300 gm. thrice

CASE RECORDS

245

boiled vegetables (cauliflower and asparagus) were added. The diet was then
rapidly increased, particularly in its fat component,, as shown in Table IX.

It is seen that the great increase of fat intake on Nov. 29 was accompanied by
sharp increase of both glycosuria and ferric chloride reactions. The simul-
taneous increase of protein in the diet did not serve to prevent this increase of
acidosis. Also it is difficult to attribute the glycosuria of 11 gm. to the increase of
only 5 gm. protein on Nov. 29, as compared with the preceding day. Further-
more, though this glycosuria was only 11 gm., because the high diet was composed
chiefly of fat, the injurious after-effect is likewise characteristic of fat. For the
entire first week in Dec. the diet was only once as high as 500 calories; Dec. 5, 6,
and 7 were fast-days with alcohol, yet the aglycosuric condition was difficult to
restore. Beginning Dec. 8 the attempt was made to build up a diet, beginning
with eggs, butter, and 'thrice cooked vegetables. Whisky was never entirely
discontinued, and in Jan. the intake represented about 65 gm. alcohol daily.
The protein was generally 40 to 60 gm.; i.e., a httle above or below 1 gm. per kg.

TABLE rx.

Date.

Diet.

Weight.

Urine.

Protein.

Fat.

Alcohol.

Calories.

Volume.

Sugar.

FeCb
reaction.

1914

em.

em.

am.

ke.

cc.

em.

Nov. 27

47

135

43

1746

50.6

1540

+

-f-l-H-

" 28

57

179

15

2005

51.6

2005

+

++

" 29

62

509

15

5096

50.5

1115

11.15

-1-4- H-

" 30

37

259

10

2629

51.3

1190

+

+++

Dec. 1

37

259

15

2664

51.0

860

+

++

of weight. The calories were kept at approximately 1000 to 1200, or about 20
to 24 calories per kg. for SO kg. body weight. The traces of glycosuria indicated
in the graphic chart were very slight, and were mostly connected with the use of
thrice cooked vegetables. The tolerance for carbohydrate was so low that
300 to 500 gm. of vegetables of Joslin's 5 per cent class, boiled through three waters
in the usual way, brought on these traces of glycosuria. In Jan. these vegetables
were omitted. The patient being an old woman with small appetite, it was pos-
sible to place her on a ration made up of coffee, soup, whisky, eggs, meat, fish,
butter, and olive oil. She remained practically sugar-free on this regimen, since
the traces of glycosuria noted thereafter were mostly very faint reactions in the
urine of single periods during the day, undiscoverable if mixed with the 24 hour
urine. The undernutrition is indicated by the continuous fall in weight during 2|
months, from 53.5 kg. on admission to 45 kg. on discharge. She was discharged
on Feb. 1, very happy with her condition. The incipient gangrene had healed
early, and she had been restored to comfort and activity. She felt able to con-

246 CHAPTER in

tinue her diet amid the difficulties of her home conditions. Slight albuminuria
and casts present on admission still continued at discharge, and the systolic
blood pressure was 205 mm.

Subsequent History. — The patient was unable to continue her diet successfully
at home. As she evidently required continuous care, she was advised to enter
a semipublic institution, where she has since lived and is kept on a moderately
restricted diet, with 1 to 3 per cent sugar constantly in the urine and continual
pain in the right foot, which does not completely disable her and has not been
accompanied by any return of actual gangrene.

Acidosis. — ^As respects acidosis, it will be noted that she entered with a nega-
tive ferric chloride reaction, evidently because of the carbohydrate in her former
diet. The ferric chloride reaction appeared on the 4th day of fasting, about as
might be expected in a normal person, and it is again nonceable that 300 calories
of alcohol did not prevent the appearance of this reaction. The reaction was
never a heavy one, and in a feeble woman of this age it was not considered ad-
visable imder the circumstances to impose the rigorous measures which wovdd
have been necessary to make the urine quickly normal. Theoretically, this con-
tinued slight acidosis and the diet keeping her barely on the verge of glycosuria
all the time were wrong, and under ideal conditions actually better results could
have been achieved by more rigid measures, cutting her diet and weight still
lower and bringing about a normal state of the urine and at least some slight
carbohydrate tolerance. Practically, there was a strong likelihood that she
would not be able to foUow the necessary diet outside the hospital, and it seemed
therefore unwise to attempt an ideal result. Under the plan pursued, her condi-
tion at discharge was a good one for her years, and by persisting in the same
program she would almost certainly have gained gradually some carbohydrate
tolerance and lost her trace of acidosis; but her mental and social state interfered
with this result.

Remarks. — This patient was admitted as presenting early diabetic gangrene
with seniUty and arteriosclerosis, the idea being to test the effect of therapy in
such a case. Simple protection and occasiohal hot air baths were the only local
measures employed, but healing proceeded uninterruptedly and apparently as
rapidly as possible at this age. It was striking that pain in the foot could at
first be produced at wiU by food. Excessive diet which brought return of glyco-
suria was found to bring complaint of pain the same day, although the patient
was kept ignorant of the laboratory tests. On discharge the foot appeared
entirely normal, except for coldness to touch and some loss of tissue in the for-
merly discolored areas. Pain, tenderness, and disability had disappeared. The
loss of weight under treatment, amounting to about one-seventh of her entrance
weight, did not serve to weaken her. On the contrary, she went out with improved
strength.

The case well illustrates a familiar therapeutic situation. In numerous cases
of diabetes in advanced senility, in one sense the diabetes is mild, the glycosuria

CASE RECORDS 247

is not excessive, the acidosis does not threaten coma, and the patient seems to
go along for years "with little injury. Some form or degree of harm ordinarily
results sooner or later, frequently, as in this case, gangrene. On treatment, the
apparently mild diabetes proves by no means easy to control. The tolerance
from the standpoint of complete sugar-freedom is surprisingly low, and months
of privation and reduction of weight and sometimes also of strength are neces-
dary to atone for the harm caused by years of lack of care. Only three courses
are open. One is rigorous and conscientious treatment, just as in a younger
patient. This is diflScult and tedious for both physician and patient; but when
circumstances permit it to be carefully carried out, the ultimate results are more
favorable than in younger persons, and the improvement of health and appar-
ently of longevity prove that the previous glycosuria was not harmless but was
largely responsible for symptoms attributed to senility or other causes. The
other extreme is complete disregard of diet. This course may be expected to
bring death from gangrene or other accident, sometimes even coma, in a large
proportion of patients. Here again due weight may not be given to diabetes as
the predisposing cause back of the infection or other terminal condition. The
middle course is one frequently adopted; namely, a moderate regulation of diet
with the aim of preserving strength and comfort and not paying too much attention
to laboratory findings. In the case of this patient, the alleged comfort of such a
course consists actually in continuous pain in the right foot and the danger of
gangrene at any time. It is also scarcely reasonable to suppose that the foot is
the only part of the body injured by the diabetes.

CASE NO. 18.

Male, unmarried, age 16 yrs. American; errand boy. Admitted Nov. 18,
1914.

Family History. — Grandparents' history not certain. Father died at, 42 of
cirrhosis of liver. Mother and two sisters of patient alive and well.

Past History. — Healthy life. Chicken-pox at 6. Tonsillitis in 1912. No
other iUnesses. Habits regular. No alcohol, very little tobacco. No exces-
sive sweets or carbohydrate. Never nervous. Ordinary weight 133 pounds.

Present Illness. — Only 3 weeks ago, during the last week of Oct., first symptoms
were noticed in the form of thirst, polyuria, polyphagia, weariness, and sleepiness.
During present month he has been unable to read by artificial light because of
blurring. Nov. 1, he stopped work and consulted a physician, who found 5 per
cent glycosuria. Patient claims to have followed restricted diet since then, in-
cluding gluten bread. He has never become sugar-free.

Physical Examination. — ^Normal in appearance though rather thin and nervous.
Teeth in good condition. Tonsils slightly enlarged. A few small palpable
glands in neck. Knee and AchiUes jerks exaggerated. Blood pressure 135
systolic, 60 diastolic. Examination otherwise negative.

248 CHAPTER m

Treatment. — The diet on Nov. 19 consisted of 105 gm. protein, 17 gm. carbo-
hydrate, and nearly 2000 calories. The glycosuria diminished to traces, and sugar-
freedom could doubtless have been readily attained without fasting. Neverthe-
less, for the sake of more rapid and radical improvement, 4 days of fasting were
imposed (Nov. 20 to 23). To make the fast easier, thrice cooked vegetables in
quantities increasing up to 1500 gm. daily were permitted. The trace of ferric
. chloride reaction which developed cleared up spontaneously.

On Nov. 24 two eggs and 20 gm. butter were added, increased on the next
day to four eggs and 40 gm. butter. Meat and bacon were subsequently added.
The negative ferric chloride reactions, Dec. 1 to 4, on diets of 2200 to 2300 calories
without carbohydrate and composed chiefly of fat, stand in strong contrast
with what other patients often show when sugar-free on the same sort
of diet. Thereafter the patient proved able to tolerate as much as 2900
calories with 60 to 80 gm. carbohydrate and 107 to 130 gm. protein. He was
dismissed on approximately this diet but with calories diminished to about 2500.
. General instructions were given, but the food was not required to be weighed.
The liberal diet (over 2 gm. protein and 50 calories per kg.) was permitted with
the idea of satisfying the patient and allowing him to work hard, and in the hope
that it might be tolerated in view of the early and mild stage of the diabetes.
The average was reduced slightly by the fast-day ordered ev^ry 2 weeks. Also
instead of weighing food, the patient was instructed to keep careful account of
his own weight and never let it go above 120 pounds {i.e. 13 pounds below his full
normal weight). Any gain over this was to be checked by fasting and reduced
diet.

Subsequent History. — Reports indicated that the patient adhered to his diet
until cherries became ripe in summer, when he started glycosuria by eating cher-
ries. As he then broke diet in other respects, he was instructed to return to the
bospital on July IS.

Second Admission. — In addition to glycosuria, decided ketonuria was present
this time, notwithstanding 125 gm. carbohydrate in the diet on July 16. 3 days
of fasting with nothing but cofiee and soup were imposed Quly 18 to 20), followed
by a carbohydrate tolerance test, starting with 20 gm. carbohydrate in the form
of green vegetables. The quantity was increased by 20 gm. carbohydrate daily,
until on Aug. 4, 350 gm. carbohydrate were taken without glycosuria. Without
attempting to push the carbohydrate higher, a fast-day was given on Aug. 5, with
only coffee and soup. A diet was then instituted of 100 gm. protein, 100 gm. car-
bohydrate, and 2600 calories. Later the carbohydrate was raised as high as 200
gm. Traces of glycosuria occurred on this diet. It is noteworthy that even with-
out glycosuria and with this high carbohydrate intake, some distinct ferric
chloride reactions were present. On Aug. 21, the carbohydrate was diminished
to 5 gm., the protein remaining about 100 gm., and the total diet about 2500
calories. On Aug. 28, 100 gm. carbohydrate were resumed, and the protein and
total diet diminished to 84 gm. and 2400 calories respectively. The patient was

CASE RECORDS 249

discharged on this diet. His weight was 56 kg. at this admission, {i.e. a return
to his full normal weight which had been forbidden) and 51.8 kg. at discharge
(still about 1 kg. higher than at his first admission) .

Subsequent History. — Nothing further was heard from the patient until a letter
from his sister.reported his death on Nov. 11, 1915. Inquiries revealed that the
mother had no control over the boy, who refused to foUow diet or allow his urine
to be tested. The physician who referred the boy to this hospital was out of
town. After the usual polyuria, polydipsia, and loss of weight and strength, the
patient late in Oct. began complaining of indigestion, and a few days before death
showed a high degree of nervousness and excitement. A local physician treated
these symptoms of acidosis with tablets for the indigestion, sedatives for the
nervousness, and tonics for the weakness. Heavy breathing was noted at the end,
but actual coma was only a few hours in duration.

Remarks. — ^The condition was at a very early and favorable stage when treat-
ment was begun. The well marked ferric chloride reactions without glycosuria
on the high carbohydrate diets of Aug. 16 to 20 possibly indicate the intrinsic
severity of the case. Undoubtedly the violations of diet and the gain in weight
between the two admissions constituted a serious setback. Nevertheless, the
carbohydrate test up to Aug. 4 showed that the tolerance was still high, and the
blood sugar later in Aug. was found to be easily brought to normal. The later
course was the t3rpical uninterrupted downward progress of severe untreated dia-
betes, owing entirely to the fault of the patient and of the local practitioner who
then treated him. No dietetic treatment could accomplish anything in a patient
so irresponsible as this.

Concerning the diets prescribed in the hospital the following may be re-
marked. The change to practically carbohydrate-free diet on Aug. 21 is the
typical old-fashioned method. It is observed that in spite of the high caloric
intake (nearly SO calories per kg.) the blood sugar promptly fell to normal and
the results might be called favorable. The fact is that the ferric chloride reaction
persisted, and continuance of such a high intake would inevitably have brought
disaster later, no matter how favorable the laboratory findings for the time being.
The diets allowed this patient were unduly high, for the following reasons. First,
it had not yet been established whether the patient at such an early stage might
recover sufficient tolerance to carry the fuU load of diet and weight. Second, this
patient was given exercise involving considerable labor (see Chapter V), and it
was anticipated that he would perform considerable muscular work at home.
Third, it was evident from his general character that he would not endure any
real privations, and he was therefore placed on a diet which left no excuse for
violations, being fuUy satisfactory in protein, carbohydrate, and total quantity,
and calling only for abstinence from sugar and reasonable limitation of starch.
As stated, later experience has made it evident that such treatment is bad, and
always results in the downward progress which was formerly regarded as spon-
taneous and inevitable. The attempt to try this method in this case failed on
account of the patient's disobedience.

250 CHAPTER ni

CASE NO. 19.

Female, married, age 39 yrs. Russian Jew; housewife. Admitted Nov. 18,
1914.

Family History.— Pa.ients lived to old age. Patient had four brothers and nine
sisters; all are living or died of typhus or accidental causes in Russia. No dia-»
betes, cancer, tuberculosis, syphilis, or nervous diseases known in family.

Past History.— Born in Russia; came to United States 26 years ago. Hy-
gienic surroundings poor. Measles and whooping-cough in childhood. Typhus,
at 12. 16 years ago a so called abscess in throat, said to have been cured by
lancing. 7 years ago patient had a convulsion after a confinement; had to be in
hospital 3 weeks and was sick for 3 months. Some shortness of breath on exer-
tion for 2 years past. She was married 18 years ago. Husband Uving and well.
Four children living and well; one born dead, full term; one miscarriage. Habits
regular, no excesses. Frugal diet, poor in sweets but also in vegetables.

Present Illness. — ^Began with pruritus vulvae li years ago. A doctor pre-
scribed a salve which was ineffective. 1 year ago polydipsia commenced. She
drank 60 glasses of water a day. Polyphagia began 6 months ago. She has lost
38 pounds during the past year, falling from her normal weight of 146 pounds
to 108 pounds. Sleeplessness, weakness, pains in back also complained of. She
consulted two different physicians who, notwithstanding these typical symptoms,
told her she was "run-down" and prescribed tonics without examining urine.
4 weeks ago she came to New York for further medical advice. Diagnosis of
diabetes was made and she was in a hospital for 2 weeks on a diet limited abso-
lutely to meat, eggs, fish, cream, cheese, and string beans. Her condition failed
to improve, and on her physician's advice she made apphcation at this Institute.
Her chief complaints are extreme weakness and persistent headaches.

Physical Examination. — A well developed woman without evident discomfort
or dyspnea, appearing only sUghtly undernourished, but with flabbiness of skin
indicating considerable loss of weight. Nephritic countenance, with slight edema
about eyes and general pallor. Ocular examination negative. Teeth show
neglect; many missing; those remaining show caries and pyorrhea. Throat ap-
pears normal. Heart normal. Slight empyema. Reflexes normal. Examina-
tion otherwise negative. Blood pressure 90 systolic, 70 diastolic. Wassermann
negative.

Treatment. — (No graphic chart.) On her first day in hospital (Nov. 18) the
patient received a carbohydrate-free diet of 12 gm. protein and 411 calories, and
excreted 8.3 gm. sugar. Notwithstanding the great weakness complained of and
the presence of nausea and colic, fasting was begun the next day and continued
for 5 days. Alcohol was permitted because of weakness, but not more than 80
cc. whisky per day could be taken because of nausea. The ferric chloride reaction
was negative on admission, positive on the first fast-day and diminished so that
it was fully negative like the sugar reaction on the 3rd day of fasting. 180 gm.

CASE RECORDS 251

thrice cooked vegetables were given on the 4th and 5th days. A very low diet
was then begun, consisting of two eggs and 500 gm. thrice boiled vegetables.
The weight, which was 47.2 kg. on admission, diminished to 44.6 kg. on Nov. 24.
The patient complained of great hunger. The diet was rapidly increased until on
Dec. 5 it consisted of 60 gm. protein, 2 gm. carbohydrate, and 3600 calories.
This was tolerated without glycosuria or ketonuria, but the carbohydrate toler-
ance was very low. On Dec. 7 the addition of 200 gm. green vegetables con-
taining 9.8 gm. carbohydrate resulted in shght glycosuria. The weight by this
time was up to 48.8 kg. and the patient was much improved subjectively. The
glycosuria was checked by a fast-day with 45 cc. whisky, then carbohydrate-free
diet resumed, at first very low (25 gm. protein and 250 calories), but again rapidly
increasing until on Dec. 19 it contained 138 gm. protein and 3330 calories. The
attempt to include 7 to 12 gm. carbohydrate in the form of green vegetables
again resulted in slight glycosuria. Without a fast-day, the carbohydrate was
stopped and the total diet diminished to 600 calories, followed by an increase as
before. On Dec. 28 the weight was 47.4 kg., and a diet of 100 gm. protein and
22 gm. carbohydrate were tolerated without glycosuria. The same was true of
the diet of 91 gm." protein and 27 carbohydrate on Dec. 29. The assimilation of
carbohydrate here is explainable by the lower weight and the lower total diet;
namely, 2200 calories on each of these days. Likewise 103 gm. protein, 24 gm.
carbohydrate, and 2400 calories were tolerated on Dec. 30. The patient was
discharged on Jan. 3, 1915, on a carbohydrate-free diet of 110 gm. protein and
2500 calories, with 600 to 800 gm. thrice cooked vegetables daily. She felt well
and fit for work and was continuously free from both glycosuria and ketonuria.
Her weight at discharge was 47.6 kg., or practically identical with the weight at
admission.

Subsequent History. — The patient followed her diet faithfully, and on Apr. 20
the addition of 10 gm. carbohydrate was permitted. Her weight tended to in-
crease, and was 50.4 kg. on Aug. 2, 1915, and 55.8 kg. on Jan. 11, 1916. She was
then instructed to take a fast-day once every 2 weeks. One feature of her his-
tory is that 7 weeks after discharge (Feb., 1915) and again in Nov., 1915, she had
severe colds or grippe with fever, which confined her to bed 1 or 2 weeks, while
no more than traces of glycosuria appeared. Her progress continued steadily
favorable, and in Jan., 1916 she was referred to another clinic for further guidance
and observation. She was seen again in Apr., 1918, still following diet and doing
her housework without complaint.

Remarks. — The case gives the usual illustration that the way for a weak and
undernourished diabetic to gain strength and well-being is by therapeutic under-
nutrition. Abrupt initial fasting is sometimes dangerous in patients showing the
condition here described at the outset, but was well borne in this instance. With
sugar-freedom and loss of weight, the patient felt distinctly better; and in view
of her age and the relative mildness of the case it was considered safe to augment
her diet rather rapidly. As is frequent in such cases, with an adequate ration of

252 CHAPTER ni

protein and calories, the carbohydrate tolerance was practically nil. With the
weakened condition and the apparent absence of tolerance, this might have been
classed in standard text-books as a severe case. The relative mildness was
shown by the steady improvement when the urine was merely kept sugar-free.
It is also of interest that occasionally patients of this sort, handicapped by ignor-
ance and poverty combined, prove able to follow diet with fidelity, test their urine
conscientiously, and achieve satisfactory results.

CASE NO. 20.

Female, married, age 38 yrs. American; housewife. Admitted Nov. 19,
1914.

Family History. — One brother died of tuberculosis at 29 years of age. Family
otherwise healthy.

Past History. — Scarlet fever, measles, chicken-pox, whooping-cough, and
diphtheria all before 7th year. Also at age of 2 patient had a fall injuring left
knee so that she was unable to walk until 13, and the leg is stiU stiff. Has had
headaches all her life. Lately they are limited to the menstrual period, and are
localized in migraine fashion on the left side of the face. Numerous sore throats
during the past year. Habits regular. No excesses, no special fondness for
sweets or starches. Married 13 years ago. One child born 12 years ago died of
heart trouble a few hours after birth. A second living and well. Venereal dis-
eases and symptoms denied.

Present Illness. — Glycosuria was discovered 1 year ago when patient went to a
hospital for another cause. Since then there have been no symptoms except the
gradual loss of SO or 60 pounds of weight. She has noticed a darkening of the skin
about her eyes during this time. This began in the form of small dots which have
increased and fused until they form a very noticeable broad brown ring around
her eyes. She has been on a moderately restricted diet with continuous glycosuria,
and has been taking sodium bicarbonate and citrate for the past few weeks.
Nervousness has developed and she tires easily. She was referred to the Insti-
tute by her physician on suspicion of bronzed diabetes.

Physical Examination. — Height ISO cm. A nervous, frightened looking woman,
well nourished, with sweetish odor of breath. Shghtly elevated bronzed circle
1| to 2 cm. wide about both eyes is most striking characteristic of face. Teeth
neglected, three missing, one carious; no pyorrhea. Throat normal. Heart
shows signs of well compensated mitral regurgitation. Blood pressure 140-
110. No enlargement of lymph nodes except in axilla. Knee jerks present
on right, absent on left (injured side). Examination otherwise negative. No
pigmentation except that about eyes.

Treatment. — Patient was first kept on an observation diet without fasting.
No special pecuharities were noticed, and she was able to tolerate 75 to 80 gm.
protein, 30 to 40 gm. carbohydrate, and 1500 to 1800 calories with no glycosuria

CASE EECOEDS 253

or only traces. Ketonuria was stubbornly persistent but never dangerous in de-
gree. Slight albuminuria present on admission cleared up completely and did not
return. The observation diet as a whole represented undernutrition, inasmuch
as the weight fell from 53 kg. at entrance to 48.5 kg. on Dec. 18. The condition
about the eyes proved to be xanthelasma, and nothing was found to indicate a
true bronzed diabetes. Accordingly a more radical treatment was instituted in
the latter part of Dec, especially with a view to reducing weight. From Dec. 20
to Jan. 6 the diet contained nothing but whisky and green vegetables. Traces of
glycosuria appeared when the carbohydrate intake was approximately 60 gm.
By this means the urine was at last made free from both sugar and ferric chloride
reactions (Jan. 5 and 6). Carbohydrate was then excluded by thrice boiling the
vegetables, and two eggs were added. The diet was then built up, so that on
Jan. 13 to 14 it consisted of about 80 to 90 gm. protein, 30 gm. carbohydrate, 60
gm. alcohol, and 2200 to 2300 calories. The weight had thus been reduced to
46.6 kg.; i.e., a loss of 6.4 kg. since admission. Though the ferric chloride reac-
tion had reappeared, it was deemed safe to let the patient go home on this theo-
retically excessive diet, in order that she might carry on her housework comfort-
ably and continue to improve in strength and nervous control, the expectation
being that in such a case and under such conditions the gradual gain in tolerance
resulting from continued sugar-freedom would take care of the persisting ab-
normalities, notably the ketonuria.

Subsequent History. — The patient adhered faithfully to her diet at home, car-
ried on her housework, nursed her daughter through pneumonia, gradually lost
her nervousness, and remained continuously free from glycosuria but with a
slight ferric chloride reaction constantly present, even with addition of 10 gm.
carbohydrate to the diet on Apr. 20. On June 2 she was readmitted to the hos-
pital because of complaint that she was not feeling so well and that her nervousness
was returning.

Second Admission. — The weight at this admission was 43.8 kg.; i.e., 2.8 kg.
less than at discharge. The general condition was much better than at the former
admission. The pigmentation about the eyes appeared neither to have increased
nor diminished. The urine was entirely free from sugar, as the patient reported
it had been continuously, but the ferric chloride reaction had become heavy, and
the 24 hour urine contained 1.96 gm. ammonia nitrogen. The symptoms com-
plained of were presumably associated with this acidosis. It was therefore
deemed desirable to proceed radically to abolish acidosis. This could not be
done by simple addition of carbohydrate to the diet, for on June 3 the giving of
30 gm. carbohydrate with 84 gm. protein and 1700 calories caused well marked
glycosuria. On the other hand, the acidosis diminished by simple reduction of
diet, so that on June 5, on a carbohydrate-free diet of 66 gm. protein and 1300
calories, there was excretion of only 0.56 gm. ammonia nitrogen. Therefore on
June 6 and 7, fast-days were given, with an allowance of 300 cc. coffee, 300 cc.
clear soup, and 50 cc. whisky. On Jime 8, alcohol was discontinued and never

254 CHAPTER III

again used for this patient. Green vegetables representing 10 gm. carbohydrate
were added on this day, and the usual carbohydrate tolerance test was instituted,
with increase of 10 gm. carbohydrate in green vegetables daily. A trace of gly-
cosuria appeared on June 14 with 90 gm. carbohydrate, but this did not represent
the true limit of tolerance, because glycosuria ceased, and the true limit was
reached only with about 150 gm. carbohydrate on June 23. Further increase
up to 170 gm. on the following days caused only slight but continuous glyco-
suria. Under this program the ferric chloride reaction became negative and the
ammonia excretion held a low level. After a fast-day on June 28, a regular
diet was gradually built up with one fast-day every week. Even with 37 to 45
gm. carbohydrate in the diet the ferric chloride reaction reappeared, but dimin-
ished, and on July 13 became negative with 67 to 75 gm. carbohydrate in a diet
otherwise composed of 75 to 100 gm. protein and 1600 to 2100 calories. The
weight on July 24 was 41.8 kg.; i.e., a loss of 2 kg. during this period in hospital,
or a loss of 11.2 kg. since her first admission. She was discharged to continue
this diet at home.

Subsequent History. — The patient continued to follow treatment faithfully,
and improvement continued with constantly normal urine. She passed through
an attack of grippe in Nov., 1915, without return of glycosuria. She has led a
fully normal life except for attention to diet, does her work easily, has lost all ner-
vousness, and feels well in every respect. In addition to her reports, she came
for personal examination on July 18, 1916. Her weight was then 45.2 kg.; i.e.,
a gain of 3.4 kg. since discharge. Her general appearance was excellent, with pig-
mentation unchanged. The urine was normal, the CO2 capacity of the plasma
50.3 per cent, the plasma sugar 0.189 per cent. This hyperglycemia received no
special treatment, for since there had been such obvious improvement before, it
was considered probable that it would continue, with ultimate reduction of blood
sugar, without more radical measures in a case of this type.

Remarks. — ^Aside from points abready noted, the case again illustrates the
benefit resulting from general therapeutic undernutrition in a patient who had
already suffered considerable loss of weight and strength from diabetes. Both
the treatment and the improvement were gradual in character. Results could
have been achieved more quickly by following up the alcohol-carbohydrate period
of Dec, 1914, with undernutrition sufficient to keep the ferric chloride reac-
tion negative, at the same time buUding up carbohydrate tolerance more rapidly.
As usual in such cases, however, the simple continuance of freedom from gly-
cosuria brought steady improvement, so that at the second admission there was
a considerable carbohydrate tolerance and acidosis was easily abolished without
interruption of the steady gain in well-being. The patient now weighs enough
for fully satisfactory looks, comfort, and strength. There is a complete con-
trast in these respects with her former condition at a higher weight. An at-
tempt to return to the former weight would doubtless bring a return of the
previous troubles. There has probably been little or no absolute improvement

CASE RECOEDS 255

in the power of assimilation, neither is there any evidence of any progressive
•decline. The patient is merely living within her assimilative power. As far as
-can be judged from the experience of nearly 3 years, she can continue to do so
without difficulty, and the general trend seems to be upward rather than
•downward.

CASE NO. 21.

Female, married, age 46 yrs. Scotch,* housewife. Admitted Nov. 20, 1914.

Family History. — Father died in accident. Mother died of heart trouble at
42. Patient was the only chUd. Diabetes, tuberculosis, cancer, syphilis, or ner-
vous disorders in any relatives denied. Patient married twice. Has had only
one child, who is alive and well; no miscarriages.

Past History. — Measles, mumps, and whooping-cough in childhood. Came
from Scotland to United States at age of 17. Scarlet fever 15 years ago. Op-
eration for ventral hernia 1 year ago. Subject to occasional headaches ever since
she can remember. Also has shortness of breath on exertion. Occasional sore
throats. No use of alcohol. Drinks six or eight small cups of tea daily. Up to
15 years ago weight was 146 pounds; since then it increased, so that at the time
of her operation a year ago it was 266 pounds. During this year she has lost
36 pounds.

Present Illness. — ^About 6 months ago patient began to notice polyuria, poly-
•dipsia, polyphagia, and increasing nervousness, with rapid loss of weight. These
have been the only symptoms. No treatment by diet.

Physical Examination. — ^Height 155 cm. A large framed, plethoric, obese
woman with dry skin, a nervous expression, and bilateral arcus senilis. Teeth
neglected, some missing; those remaining show caries and pyorrhea. Tonsils a
trifle hypertrophied. Slightly large thyroid palpable. No lymph node enlarge-
ment. Heart slightly enlarged. Slight emphysema. Knee jerks active. Leg
veins markedly varicosed. Blood pressure 175 systolic, 120 diastolic. Trace of
albumin in urine, but no casts.

Treatment. — ^The most obvious requirement was to reduce weight. The most
noteworthy initial observation was that in 4 days of absolute fasting this very
•obese woman failed to develop any ferric chloride reaction and showed abso-
lutely no symptoms of acidosis. On the following 4 days she received only mod-
erate quantities of whisky (not above SO gm. alcohol) . It is evident that they did
not prevent the appearance of a slight ferric chloride reaction. This reaction was
(negative on Nov. 28, when only 10 gm. alcohol were given, as if the larger quan-
tities of alcohol had tended to produce rather than prevent it. On Nov. 29, a
•carbohydrate-free diet of 93 gm. protein and 2260 calories caused a trace of
glycosiuia. The subsequent diets represent very marked undernutrition. It is
obvious from the graphic record that the patient not only had practically no car-
bohydrate tolerance but also tended to show traces of glycosuria even on very
low carbohydrate-free diets. She was of the type spoken of in older text-books

256 CHAPTER in

as relatively independent of diet ("paradoxical tolerance"). That is, her glyco-
suria had never been excessive, and if tested she would doubtless have proved her
abihty to assimilate most of the carbohydrate of any diet. Yet complete sugar-
freedom was difficult to achieve even with the most radical restrictions. Blood
sugar analyses were not made. It is probable that a continuous marked hyper-
glycemia was responsible for the frequent traces of glycosuria, and that this
varied Uttle with diet. The principal result of treatment was to bring the body
weight down from 108 kg. to 90 kg. No special attempt was made to conserve
the body protein. Nitrogen balances would undoubtedly have turned out strongly
negative. Nevertheless, there was a gain in well-being, and at discharge there were
no symptoms except those referable to arteriosclerosis, the former migraine attacks,
and other conditions apparently independent of the diabetes. The diet pre-
scribed at dismissal was approximately 75 gm. protein, 60 gm. carbohydrate, and
1300 calories, representing, for a weight of 90 kg., only about 0.8 gm. protein and
IS calories per kg. The trace of glycosuria on Jan. 24 may be regarded as of
the accidental type sometimes resulting from a sudden increase of carbohydrate.
It appeared that the patient could carry this diet without glycosuria and with a
bare trace of ferric chloride reaction. She stated that her appetite was reasonably
well satisfied, and she felt better when eating and weighing less. The trace of
albumin present in the urine at admission remained unchanged, but casts could
very seldom be found. The treatment was not considered complete at dismissal,
but undernutrition was to be continued at home.

Subsequent History. — The patient continued free from glycosuria at home,
with a persisting trace of ferric chloride reaction. She was not required to weigh
her food, and her estimates were probably enlarged with increase of appetite, for
her weight at first held practically even, being 90.6 kg. in Aug., 1915. By Oct.
there was an increase of 2.6 kg. The sugar in the whole blood was then 0.128 per
cent, in the plasma 0.161 per cent. Sugar remained absent from the urine; the
ferric chloride reaction continued present. She was instructed to fast 1 day every
2 weeks."

On Nov. 29, the weight was found to be 101.4 kg., plasma sugar 0.143 per cent,
CO2 capacity of plasma 43.2 per cent. The blood pressure was 240 systolic, 140
diastolic, and there had been symptoms referable to hj^jertension. She was
instructed to fast IJ days every week.

On Jan. 11, 1916, the blood pressure was 220 systoUc, 120 diastolic. The weight
was 101.5 kg. with clothing, 99 kg. stripped. She was instructed to remain in bed
for a week on a diet of nothing but low percentage green vegetables. The urine
was entirely negative for both sugar and ferric chloride reactions.

On July 13, 1916, the blood sugar was 0.128 per cent, plasma sugar 0.156 per
cent, CO2 capacity 56.9 per cent. Sugar and ferric chloride reactions in urine
remained negative. Though recent dietary instructions theoretically estab-
lished an intake of only 1000 calories, the patient's estimates were evidently too
high and the weight continued to rise, being now 103.2 kg. stripped. The patient

CASE EECORDS 257

has remained so well that she has not been closely supervised. She still con-
tinues to lead a normal life, and suffers only from headaches and occasional attacks
referable to hypertension.

Remarks. — Complication of this case with obesity and arterial hypertension
called for no special alteration in the treatment of the diabetes. The entire
condition rendered a reduction of weight desirable. By this simple measure
the carbohydrate tolerance, which appeared so very low, was easily raised, and
the case stood revealed in its true light as one of intrinsically mild diabetes. It
must again be mentioned that the initial stage of treatment of such a case some-
times presents difficulties and dangers such that fasting may have to be em-
ployed cautiously and after special preparation; but in this instance the fasting
offered no difficulty and the obesity was no obstacle to the gradual disappearance
of the ferric chloride reaction. The case thus opposes the idea that the available
' fat supply is the sole determining factor in fasting acidosis. Under a mild thera-
peutic regime hj^perglycemia has been persistent. It need not be attributed in
any degree to the hypertension; on the contrary, the hyperglycemia sometimes
described in cases of hypertension is more probably an indication of pancreatitis
and mild diabetes. This being one of the earlier cases of the series, conservatism
seemed to favor leniency in the treatment. Fuller experience indicates that the
right plan would be to reduce the weight sufficiently to keep the blood sugar nor-
mal. Nevertheless, in view of the mUdness of the case, if the patient follows a
fairly reasonable diet without letting her weight rise too high, she can probably
go through life without further trouble from her diabetes.

CASE NO. 22.

Male, married, age 52 yrs. American Jew; cigar manufacturer. Admitted
Nov. 20, 1914.

Family History. — Father died of pneumonia at 74. Mother, now 74, has kid-
ney trouble. One brother living and well. Two sisters died in childhood, a
third of appendicitis at IS, a fourth is living but has carcinoma of breast. No
tuberculosis, syphilis, or nervous disorders in family. Patient has been married
31 years; wife living and well. Five children; one died of diphtheria in infancy,
four living and well.

Past History. — Practically never sick from childhood up. Neisser infection
twice. Syphilis denied. At age of 21 patient was rejected for life insurance
because of alleged B right's disease. He consulted eminent specialists, and the
slight albuminuria was classified among the earliest examples of orthostatic al-
bimiinuria. For many years he has never been without albumin and casts in
urine, but has had no symptoms other than these and has never had to miss a
single day from business. For part of his life patient drank considerable wine in
connection with business dealings, and smoked IS to 20 cigars a day. He started
as a poor boy and became a millionaire, and has lived at highest nervous tension.

258 CHAPTER III

In the past 10 or 12 years he has had 25 or 30 hysteric attacks in which he was
practically irresponsible. He is accustomed to rich Uving. Bowels constipated.

Present Illness. — 2 years before admission sjrmptoms began with extreme
himger and thirst, loss of weight, bad breath, and cramps in the legs. On ac-
count of failing vision he consulted an oculist, who immediately asked for a
specimen of urine and diagnosed diabetes. The diet since then has been sUghtly
restricted qualitatively, but quantitatively two or three times as much as re-
quired by a normal appetite. The loss of weight has continued nevertheless.

Physical Examination. — ^A shghtly buUt, somewhat emaciated man with pale
complexion and nervous, feeble appearance. Several teeth missing; those pres-
ent show sUght caries and pyorrhea. Throat somewhat congested; left tonsil not
visible, right protrudes slightly. Shght generalized lymph node enlargement.
Heart very shghtly enlarged to left. Arteries palpably sclerosed. Blood pres-
sure 135 systoUc, 110 diastohc. Liver edge 2 cm. below costal margin. Reflexes
normal. Examination otherwise negative. Urine shows shght albumin and
numerous hyahne casts.

Treatment. — The patient's extreme nervousness, as also headaches and ter-
rors at night, required the use of codeine during the early days in the hospital.
He was kept on an observation diet for the first 3 days, poor in carbohydrate, and
particularly with total calories limited to about 1600 on Nov. 21 and 900 on
Nov. 22. The glycosuria was thus greatly diminished. Nevertheless fasting was
instituted as soon as the general condition seemed to permit. Owing to weak-
ness, the patient was in bed during the fast. On Nov. 23 and 28 the fasting
was absolute. On the intervening days whisky was given, but never above 70
cc. Glycosuria ceased with the first day of fasting. With continuance of the
fast, the ferric chloride reaction diminished to traces. On Nov. 29 a carbohy-
drate-free diet of 45 gm. protein and 2080 calories was tolerated without glyco-
suria, but brought back a heavy ferric chloride reaction. On the next day the
diet was diminished to 23 gm. protein and 600 calories. The weakness and
nervousness stiU being salient features and the patient being very hungry, a lib-
eral diet was permitted on the subsequent days, rising by Dec. 19 to 97 gm. pro-
tein, 33 gm. carbohydrate, and 3000 calories. Traces of glycosuria were fre-
quent on this high diet, and well marked ferric chloride reactions continued. By
this time the general condition had improved and the patient had grown more
accustomed to hospital hfe and dietary restrictions. Accordingly, on Dec. 21 a
more rigid treatment of the diabetes was undertaken. On that day the only
food was 50 gm.. alcohol. Green vegetables were gradually added to the alcohol,
representing 7.5 gm. carbohydrate on Dec. 22 and increasing to 107 gm. on Dec.
28. The ferric chloride reaction was still stubborn notwithstanding this car-
bohydrate intake without glycosuria — an illustration that food is not the only
controlling factor. In view of the patient's weakness and irritability a more
Uberal diet was again resumed. He was dismissed on Jan. IS, 1915, on a diet of
approximately 100 gm. protein, 15 gm. carbohydrate, and 2400 calories. The body

CASE RECORDS 259

weight was SO kg. at admission, 47.2 kg. at discharge, the period of treatment thus
representing undernutrition to the extent of a loss of 2.8 kg. weight. There had
been a notable gain in strength, so that the patient was now outdoors daily and
was becoming restless owing to a desire to return to work. The nervousness was
greatly lessened and he felt that hfe was again worth hving. Albuminuria and
casts persisted, but several functional tests during the stay in hospital had shown
a normal index of urea excretion. The patient, being stiU weak, was instructed
not to work more than half of each day and to pay attention to rest and general
hygienic measures.

Subsequent History. — ^The urine continued negative to sugar and ferric chloride
tests, with the usual albumin and casts present. By Feb. 10 the weight had
risen to 53.2 kg. The blood pressure was 153 systoUc. The patient at this time
was working 6 or 7 hours a day, was taking horseback rides and other exercise,
and reported himself free from nervousness, sleeping soundly at night, and en-
joying life. In appearance he was very greatly improved. By Apr. 12 there had
been a further increase of 2 kg. in weight. The blood pressure was 180 systolic,
135 diastohc. He was warned that the gain in weight was contrary to instruc-
tions, and the diet was ordered changed to 115 gra. protein, 20 gm. carbohydrate,
and 1600 calories; i.e., the protein and carbohydrate were slightly increased and
the fat decidedly diminished. This allowance of about 30 calories per kg. was
expected to maintain his nutrition without further increase of weight. On July 7
the patient reported that he had been f eeUng as well as in his earlier years be-
fore the onset of diabetes. Occasional headaches recurred but were reheved by
catharsis. There had been a further sHght increase of weight up to 54.4 kg.
The blood pressure was 195 systolic, 160 diastolic. The patient had departed
sUghtly from diet, particularly by adding bread occasionally, and the urine showed
a trace of glycosuria and a moderate ferric chloride reaction. This trace always
disappeared with a single fast-day, and he was warned to adhere to diet and keep
sugar absent.

Second Admission. — ^The patient made no further report until he reentered the
hospital Jan. 24, 1916, slightly more than a year after discharge. He had car-
ried on his large business continuously and efl&ciently during this time and also
had enjoyed much recreation. He returned with glycosuria again present, in con-
sequence of too many visits to restaurants in the course of his amusements. The
weight was 50.2 kg.; i.e., 0.2 kg. more than at previous admission. He had been
running down lately by reason of his indiscretions in diet, but nevertheless was far
stronger and in better condition in all respects than at his previous admission.
Physical examination practically as before. Blood pressure 200 systohc, 135 dias-
tolic. AU the conditions being more favorable, measures were now instituted for a
radical clearing up of both glycosuria and ketonuria. 4 days of absolute fasting
were imposed (Jan. 28 to 31). This was followed by a carbohydrate period in
the form of the usual tolerance test, i.e. on Feb. 1 green vegetables were given
containing 10 gm. carbohydrate, and this was increased by 10 gm. daily. The

260 CHAPTER rn

traces of glycosuria on Feb. 4 and 5 were accidental in character and disap-
peared with further increase of carbohydrate intake. A tolerance of 150 gm.
carbohydrate was thus demonstrated on Feb. 15. By this time the ferric chloride
was entirely negative, the blood pressure had gradually diminished to 160 sys-
tolic, 120 diastolic, and the patient was feeling well enough to have recovered
from the fears which had brought him back to the hospital. Accordingly at this
point he suddenly announced that urgent business matters required his attention
and that he must leave immediately. He was therefore discharged on the fol-
lowing day with instructions not to return.

Third Admission. — ^Nothing more was heard from him until on Oct. 17, 1916,
his wife telephoned that he had had an attack of apoplexy and was in a critical
condition. He was found in an excessively excited state, with partial right sided
hemiplegia. The body weight was again 50.2 kg.; the blood pressure 190 systolic,
125 diastolic, the blood sugar 0.305 per cent, the CO: capacity of the plasma 81
per cent. Xhe urine showed moderate sugar and negative ferric chloride reac-
tions. He was placed on a diet of 65 gm. protein, 10 gm. carbohydrate, and 1000
calories. On this diet glycosuria diminished to only occasional traces, but the
blood sugar never fell below 0.2 per cent. Only slight glycosuria resulted from
an increase of diet to 65 gm. protein, 35 gm. carbohydrate, and 1600 calories.
Meanwhile, with rest, the paralysis was gradually clearing up. In Dec. and Jan.
it seemed feasible again to undertake thorough treatment of the diabetes. A
week of fasting (Jan. 7 to 13) was well borne. At the end of it the ferric chloride
reaction was negative, the ammonia nitrogen excretion only 0.12 gm., the plasma
bicarbonate 68 per cent, but the blood sugar was stiU 0.222 per cent. A car-
bohydrate test with the usual increase of 10 gm. daily showed a tolerance of
only 30 gm. carbohydrate in the form of green vegetables. Treatment was con-
ducted according to the usual principles, the protein being kept low (50 gm. or
less daily) partly on account of the renal condition. Rigorous imdernutrition
brought the usual results, so that in Feb. a tolerance of 120 gm. carbohydrate
was demonstrated, and the stubborn hyperglycemia was at last reduced, not to
normal, but well below the renal threshold. By Mar. the patient was able to
tolerate 65 gm. protein, 10 gm. carbohydrate, and 1400 calories. His weight had
been reduced to 41 kg.; i.e., a loss of 9.2 kg. The paralysis had gradually di-
minished so that he was able to be about again and to make some use of his
right arm. He was improved sufficiently that he was no longer trustworthy in
regard to diet. He was discharged with the feeling that life could not be greatly
prolonged.

Remarks. — ^The case represents the treatment of diabetes in the presence of
nephritis. It is evident that such a combination presents no obstacle to the
carrying out of the usual method. A diet low in both protein and calories is
beneficial from the standpoint of both the diabetes and the nephritis, and there
is no antagonism in any of the measures required. In this instance the patient
was saved from threatening weakness and nervous collapse connected with his

CASE RECORDS 261

diabetes, and it was possible, as shown especially in the second admission, to
make the urine normal and bring the blood sugar also to a normal level. Disaster
came from the side of the nephritis. The patient is failing but was alive at
last report.

CASE NO. 23.

Male, married, age 44 yrs. American; insurance agent. Admitted Nov. 27,
1914.

Family History. — Father and mother living and well. One sister died in in-
fancy, and a brother of pneumonia. No diabetes or other special disease in
family. Patient married 20 years. Two children, one living and well at 17
years; the other died in a difficult labor. An interesting addition to this history
at time of admission is that patient's mother has since developed diabetes at the
age of 74.

Fast History. — Measles, mumps, and chicken-pox in childhood. Healthy life.
Neisser infection at 19; syphilis denied. 14 years ago had "bloody dysentery"
for a week. Habits regular; moderate drinking and smoking. Appetite normal.

Present Illness. — 9 years ago, after much worry in business, glycosuria was
discovered when patient applied for life insurance. His family physician pre-
scribed diet and pronounced the condition only a transient glycosuria. Subse-
quently life insurance was granted. He has had constant medical supervision
and the tendency to glycosuria has steadily increased, so that during the past 2
years he has never been sugar-free, and the amount has varied from 3 to 7 per
cent. His weight has diminished from 195 to. 165 pounds. He can stUl do con-
siderable work, but 'feels a decided impairment of strength and endurance. No
polyphagia. Urine not more than 3 liters. He avoids sugar and most starches,
but his diet includes oatmeal, two sUces of fraudulent gluten bread, fruits, vege-
tables, and occasionally a potato. He was referred to the Institute by a com-
petent general practitioner because both glycosuria and ketonuria were heavy on
the diet stated. The physician was in the old-time dilemma of hesitating to
increase glycosuria by adding carbohydrate, and fearing to increase acidosis by
withdrawing carbohydrate.

Physical Examination. — Height 172.5 cm. A well developed, adequately
nourished, healthy appearing man. Teeth in good condition. Tonsils slightly
enlarged. Liver edge 3 cm. below costal margin. Examination otherwise
negative.

Treatment. — ^The patient was kept for a week on an observation diet of 95 to
120 gm. protein, 10 to 20 gm. carbohydrate, and 1800 to 2400 calories. The
highest anunonia nitrogen excretion was 2.31 gm. There were no symptoms of
danger or even discomfort. Fasting was begun on Dec. 5, first absolute, then (Dec.
6 and 7) with alcohol up to 52.5 gm. This was followed by a low carbohydrate-
free diet, but glycosuria promptly returned (Dec. 10 to 11) on about 50 gm.
protein and 1600 calories. Ferric chloride reactions persisted, and the ammonia

262 CHAPTER III

excretion was practically as high as at the beginning. The case had been taken as
a mild one. These signs indicated that notwithstanding the absence of striking
symptoms, the real condition was by no means trivial and nothing but radical
undernutrition could bring a satisfactory result. The patient was absolutely
obedient and gave his full confidence, and a rigid program was therefore insti-
tuted. With a view to combating acidosis, food was given chiefly in the form of
alcohol, the highest intake being about 260 cc. whisky on certain days in Feb.
The general plan of treatment is best seen from the graphic chart. Protein-fat
diets were given on a few days, for example, Jan. IS to 17, but for the most part
the diet consisted only of whisky with addition of carbohydrate from time to
time up to the limit of tolerance. This hmit was very low. The giving of 40 to
70 gm. carbohydrate in the form of green vegetables with no other food but
whisky was sufficient to cause glycosuria on repeated occasions in Dec, Jan.,
and Feb. The maximum alcohol doses above mentioned, with the addition of
these quantities of carbohydrate, failed to abolish the persistent, fairly heavy
ferric chloride reactions. Also it was not possible to allow an adequate diet and
await a later recovery of tolerance for clearing up acidosis, because the total food
tolerance remained persistently low. For example, on Jan. 17 a carbohydrate-
free diet of 89 gm. protein and 1790 calories gave rise to glycosuria lasting 2 days.
Under such conditions it is generally necessary to master both the glycosuria and
the acidosis before much real improvement of assimilation can be expected. At
the end of Mar. and first of Apr. the patient's weight touched its lowest point,
51.4 kg.; i.e., a loss of 19.2 kg. during 4 months of severe continuous under-
nutrition. The patient had come to the hospital looking strong and robust.
By this time he appeared thin and weak. His strength was definitely dimin-
ished, and his general decline seemed so evident that only fuU confidence on his
part and on the part of those conducting the treatment permitted the completion
of the necessary program. But about this time the ferric chloride reactions grew
steadily paler, until they were negative in certain urine specimens of each day and
not more than traces in the other periods. Also a recovery of assimilation was
evident, such that on Apr. S to 7 a diet of approximately 100 gm. protein, 20 gm.
carbohydrate, 100 gm. alcohol, and 2200 calories was tolerated without glycosuria.
Exercise had not been employed in the earUer treatment, because of uncertainty as
to its effects in the presence of marked undernutrition and a persistent tendency
to acidosis. It was now begun and rapidly increased up to the hmit of strength.
The high calories in the later diets were permitted in proportion to the amount of
physical labor performed. On Apr. 8 it appeared feasible to discontinue alcohol,
and except for the fast-day on Apr. 11 it was never resumed. On Apr. 9 and 10 the
diet was made approximately 100 gm. protein, 30 gm. carbohydrate, and 1500 cal-
ories. This was increased rapidly to 2700 to 3000 calpries with the same protein
and carbohydrate. A regular fast-day each week diminished the average intake
to about 86 gm. protein and 2300 calories daily, or about 43 calories per kg. for
the weight of approximately 54 kg. at that time.

CASE RECORDS 263

The patient, though thinner, now both felt and looked far better than at ad-
mission. He was up to full strength in every way and able to carry on his regu-
lar business and in addition take much exercise and recreation daily. He was
discharged in this condition on May 8 to spend the summer in the country. He
was instructed to report in 6 weeks and not to gain more than 2 pounds in this
time.

Subsequent History. — In the country he spent his days in walking, riding, swim-
ming, tennis, and other exercise, buUding up strength while keeping weight
within prescribed limits. In Aug. ferric chloride reactions ceased to appear.
The urine never showed sugar except traces on rare occasions when he made
unintentional mistakes in diet. He returned to resume his regular business in the
city in Sept.

On account of persistent hyperglycemia, exercise was increased, the patient
preferring this to a reduction in diet. Daily exercise was taken in the form of
horseback riding, athletic exercises under an instructor, swimming, and boxing.
He also walks to business, an average of about 8 mUes daily, frequently walks
20 or 30 miles on Sundays, and also plays tennis and squash three or four times a
week. His business duties occupy about 5 hours a day, and in the remaining
hours he has made a trained athlete of himself. Because hyperglycemia stiU
persisted, on Dec. 17 the diet was made 130 gm. protein, SO gm. carbohydrate,
and 2500 calories, this change representing particularly an increasd in carbo-
hydrate and a diminution in total calories. At the same time he was allowed to
increase his office work by 1 hour. On New Years day, 1916, the patient added
a large baked potato to his diet without glycosuria, but was warned against a
repetition. Traces of glycosuria appeared in subsequent months on rare occa-
sions, and accordingly on July 10, 1916, the diet was diminished to 130 gm.
protein, 40 gm. carbohydrate, and 2200 calories. In the entire time since then
there was a trace of sugar in the urine only on 2 days. The weight at last report
was 68.4 kg., in comparison with the 70.6 kg. at the time of first beginning treat-
ment in hospital. The general strength and subjective condition are the best
the patient ever enjoyed.

Acidosis. — Though mostly shght, this was notably stubborn, and the mastery
of it was one of the most difficult features of the treatment. The prolonged pro-
gram of undernutrition, with alcohol short of intoxication and carbohydrate to the
point of glycosuria, resulted in a slow decline of the ammonia to a normal level
about the middle of Feb. There was a prompt rise with the addition of small
quantities of protein and fat to the diet late in Feb. and early in Mar., followed
by another slow decline. Also, in addition to the tenaciously persistent ferric
chloride reaction, the CO2 capacity of the plasma indicated the same chronic ten-
dency to acidosis. From the graphic curve it can be seen that the values were
generally near the lower normal limit and frequently fell considerably below this.
Sodium bicarbonate was used twice; namely, SO gm. on 1 day to check the par-
ticularly marked fall of the plasma alkalinity at the close of Feb., and 30 gm.

264 CHAPTER m

daUy on Mar. 8 and 9. These doses gave immediate relief from slight symptoms
of malaise of which the patient complained at this time. But obviously his fun-
damental trouble was not lack of alkali, and the treatment had to be directed
to the causes imderlying the state of acidosis.

At the time of discharge from hospital the ammonia nitrogen excretion was stiU
0.8 to 1.2 gm.; and some color was shown with ferric chloride in certain urine
specimens every day, while specimens in other portions of the day were negative.
As mentioned, the ferric chloride reactions became fully negative in Aug. and
have remained so since. Acidosis has also remained absent by other tests. On
July 25, 1916, the CO2 capacity of the plasma was 60.6 per cent, and it has since
remained high.

Exercise and Blood Sugar. — It seems probable from other experience that no
harm would have been done and progress might have been hastened by using ex-
ercise in this case from the outset. The improved assimilation of carbohydrate
and other food might have aided in a quicker clearing up of acidosis. Exercise
was carried to a higher point in this patient than in any other of the series. As
stated, he has made a trained athlete of himself and has enjoyed the highest
vigor and subjective health. In a general way it seemed evident that exercise
improved his assimilation. Precise experiments concerning the effect of exercise
upon his blood sugar were not performed.

It will be noted in the graphic chart that the blood sugar in the latter part of
Mar. was below 0.15 per cent and fell to normal. With the higher carbohydrate
and higher total diet in Apr. it rose as high as 0.17 per cent, but came down,
apparently as a result of exercise, to a nearly normal level at discharge. After
leaving hospital the patient's weight gradually rose and the blood sugar likewise
increased. On Oct. 6, with weight up to 60.9 kg., the sugar in whole blood was
0.185 per cent, in plasma 0.208 per cent. It was at this point that a maximum of
exercise was begun, the patient preferring this to a reduction of diet. Nevertheless
on Oct. 18 the sugar in the whole blood was 0.192 per cent, in the plasma 0.208
per cent, whUe the patient was feeling in splendid condition. On Oct. 25 the
blood sugar was again 0.192 per cent and the plasma sugar 0.208 per cent; on Oct.
28 the plasma sugar was 0.222 per cent; on Nov. 15 the blood sugar was 0.161 per
cent, plasma sugar 0.222 per cent. Traces of glycosuria had formerly been cleared
up on repeated occasions by exercise, but it seemed evident that the diet was too
high, so that exercise could not lower the hjrperglycemia or entirely prevent re-
currences of these traces of sugar. Accordingly the diet was modified on Dec.
27 as above noted. On July 10, 1916, the blood sugar was 0.156 per cent, the
plasma sugar 0.217 per cent. The weight as above mentioned was higher than
before; namely, 68.4 kg. On July 25 the blood sugar was 0.143 per cent, the
plasma sugar 0.169 per cent. On Aug. 2, 1916, the blood sugar was 0.167 per
cent, the plasma" sugar 0.178 per cent. A reduction of body weight is the one
means which may be expected to control the hyperglycemia. The chief value of
exercise from the standpoint of permanent results probably consists in buming

CASE RECORDS

265

up surplus calories and keeping down excess weight. Exercise has doubtless been
somewhat overdone in this case.

Nitrogen Loss. — In the prolonged period of almost protein-free diet, it is evi-
dent that much protein must have been lost from the body. The nitrogen analy-
ses of the urine are very incomplete. If the known points of the nitrogen output
are joined to make a curve as shown in the graphic chart, a reckoning from such a
curve win give a rough idea of the depletion of body nitrogen. The general
undernutrition is evident from the following table:

Total nitrogen output

Protein intake

Nitrogen "

" deficit (output — intake)

Alcohol calories in diet

Food " " "

Total " " "

77 days.

Per day

(average) .

511.32

gm.

6.61

gm.

1236.20

It

16.10

{{

197.80

tt

2.50

u

313.52

tt

4.14

tt

28979

376

24284

316

53263

692

Alcohol. — Prolonged high dosage of alcohol in this patient was for the purpose
of kpeping up strength by supplying calories and if possible aiding to diminish
acidosis. According to clinical indications it was of value for the first purpose.
There is no evidence that it had any value for the second purpose. If the thing
were to be done over, less alcohol or none would be used. Better and quicker
results could doubtless be obtained by a low protein diet, without fat, with vege-
table periods interspersed. Body nitrogen and strength would be better con-
served by the protein. Alcohol is probably injurious rather than beneficial as
regards acidosis.

Remarks. — ^The outstanding feature of this case is that a patient in seemingly
good physical condition was subjected to over 3 months of continuous under-
nutrition and brought into a thinner and seemingly worse condition as a thera-
peutic measure on the basis of laboratory findings alone. The case was not
mUd as imagined when the patient was admitted. It is believed, on the con-
trary, that trouble was shortly impending. The condition confronted was an
assimilation of carbohydrate or protein so low that glycosuria resulted from a
very low intake, and a mild but very stubborn acidosis. An attempt to give any
considerable quantities of protein and carbohydrate would have resulted in con-
tinuous glycosuria. The use of any considerable quantities of fat would have in-
creased or prolonged the acidosis. Accordingly the only escape lay in undernutri-
tion until this dilemma could be broken. The undernutrition was therefore pushed
to the necessary point without hesitation because of any clinical appearances.
The result was successful as stated, and it is believed that a successful result
could not have been attained on any program overtaxing the patient's tolerance

266 CHAPTER ni

on the side of either carbohydrate or fat. The ultimate outcome has been good
from both the clinical and the laboratory standpoints. The persistent hyper-
glycemia is the one unfavorable feature. Unless it diminishes in the natural
course of improvement under present treatment, a reduction of body weight will
have to be ordered; otherwise there may be downward progress and somebody
may call it spontaneous. With simple precautions now, the situation promises
a favorable outcome of an unexpectedly difficult case.

CASE NO. 24.

Male, married, age 44 yrs. American; manufacturer. Admitted Nov. 28,
1914.

Family History. — Father and mother still ahve. The former has glycosuria,
discovered 4 years ago, but no other symptoms.' A paternal aunt died of cancer.
A brother and a sister of the patient are well. Patient has been married 30 years.
Wife had two miscarriages, then one chUd, who is ahve, aged 19.

Past History.— Healthy hfe, spent in small town in Indiana. Measles and
mumps in childhood. Neisser infection at 19. SyphUis denied. Rheumatism
10 years ago; joints involved successively and very painful; night sweats; illness
lasted about 6 weeks but was not severe enough to confine to bed. Occasional
sore throats before and since this time. 8 years ago patient had indigestion,
with pain after eating, pale feces, and yellowness of skin. This continued about
a year and he lost 25 pounds weight, but finally recovered under forced feeding.
No fever or sharp pain at any time. There is a discharge from the left ear
dating from boyhood. Hearing is much impaired in this ear. No excesses in
alcohol or food. For many years he smoked 6 to 10 cigars daily. Last Mar.
he diminished his smoking to a minimum; has noticed no benefit. Normal
weight is 165 pounds.

Present Illness.— 7 years ago, on account of loss of weight, extra food was
taken and considerable candy eaten. There was no special appetite, and no
thirst or other symptoms, and the food and candy were taken merely with the
idea of putting on weight. His eyesight then began to fail, and he consulted an
ocuUst who examined the urine and diagnosed diabetes. A diet was later pre-
scribed, and on this he regained some weight. Within a year, however, there
was further loss of weight, and polyphagia, polydipsia, and polyuria were pres-
ent. He then spent 10 days in a diabetic sanitarium, and became sugar-free for
the first time in 10 months on carbohydrate-free diet with whisky and sodium
bicarbonate. For the past 5 years he has made annual trips to this sanitarium,
remaining for 10 days to 10 weeks at a time. During the past 3 or 4 years he
has not become sugar-free on these trips. During the past year he was worn out
by nerve strain attendant upon a defalcation and a lawsuit. On the last day
of the trial he had to be carried to court on a cot to testify, and has been bed-fast

'The father refused all dietary restrictions, and died of diabetes in Jan., 1919.

CASE RECORDS 267

for the 2 months since that time. He was brought to this Institute from Indiana
with his physician in attendance, and had to be wheeled or carried.

Physical Examination. — Height 173 cm. A well developed, extremely emaci-
ated man, showing evidence of profound weakness but no acute distress. Teeth
in good condition. Throat congested. Slight enlargement of lymph nodes in
left axilla and groins. Knee jerks sluggish. Routine examination otherwise nega-
tive. The most striking feature aside from the emaciation is a lemon yellow color
of the skin, most pronounced on the face, but noticeable also over most of the
body; the conjunctivae are bluish white and not jaundiced, and the urine is
free from bile. The color suggests pernicious anemia. Blood examination
showed hemoglobin 80 per cent, red cells 4,000,000, leucocytes 6,000, with normal
differential count. Lipemia of heaviest degree present; plasma hke cream. Was-
sermann negative. Urine free from albumin and casts. Blood pressure only 70
systolic, diastolic doubtful at about SS.

Treatment. — Because of the extreme weakness and the absence of threatening
acidosis, the patient was given for 2 days a diet Hke that to which he had been
accustomed; i.e., on Nov. 28 and 29 about 100 gm. protein, 20 to 30 gm. carbohy-
drate, and 2000 to 2100 calories. On Nov. 29 he excreted 45 gm. sugar and 2.5
gm. ammonia nitrogen; on Nov. 30 (the first fast-day), 20.5 gm. sugar and 2.78
gm. ammonia nitrogen. Fasting was begun on Nov. 30, with some misgivings on
account of weakness. Because of tendency to nausea only 30 gm. alcohol were
given the first day, increased to 70 gm. by Dec. 5. Glycosuria was absent by
Dec. 5, and the ammonia nitrogen had diminished to 0.88 gm. (total N output
3.83 gm.). The ferric chloride reaction was much diminished but still well
marked, and the blood plasma was still intensely lipemic. The patient's strength
showed no dechne whatever on account of the fasting, and possibly a slight im-
provement. He was able to sit up in bed to read, and could walk to the bath-
room with assistance. The fasting was therefore prolonged through Dec. 6,
making 6 days. On Dec. 7, one egg, 10 gm. butter, and 500 gm. thrice cooked
vegetables were added to the whisky. This was increased daily, so that on Dec.
10 the intake was 52 gm. protein and 1450 calories. On this diet a glycosuria
of 9.9 gm. appeared. A fast-day with 100 cc. whisky on Dec. 12 failed to clear
up the glycosuria. Only one egg and 20 gm. butter were added to the whisky
on Dec. 13, yet glycosuria persisted. On Dec. 14, another fast-day with 140
cc. whisky cleared up the sugar and the ferric chloride reactions. On Dec. 15, a
diet of only 17 gm. protein and 600 calories (450 of which were alcohol) caused
glycosuria of 2.61 gm., this sugar being doubtless partly attributable to the 1000
gm. thrice cooked vegetables allowed for the sake of bulk. This glycosuria per-
sisted under similar conditions on Dec. 16, so that a fast-day with 140 cc. whisky
became necessary on Dec. 17. . Beginning Dec. 18, all vegetables were omitted
in the attempt to build up strength. A diet was given on Dec. 18 and 19 of 52
gm. protein in the form of eggs, 420 calories of alcohol, and olive oil to bring the
total calories up to 2600. The ammonia excretion rose, and persistent traces of
glycosuria appeared. The diet was sharply reduced, so that on Dec. 21 it con-

268 CHAPTER III

sisted of only two eggs and 130 cc. whisky. The eggs were increased until on
Dec. 26 seven were given. Though such diets were frequently below 1000 cal-
ories and composed largely of alcohol, traces of glycosuria remained persistent.
It became established during this time that the patient could not tolerate even
the carbohydrate of 200 gm. thrice boiled vegetables such as celery or Brussels
sprouts, and the protein of six or seven eggs also sufficed to cause glycosuria.
Under such circumstances the prospects for nourishing a patient already seri-
ously weak seemed hopeless. But the notable feature was that the patient's
strength and spirits continually improved during the time when he should theo-
retically have been starving. He became able to sit up in a chair, but was con-
fined to bed almost continuously under orders.

On Jan. 5, 50 cc. whisky, 200 gm. thrice boiled celery, and 100 gm. thrice
boiled asparagus were taken without glycosuria. On Jan. 6, meat and bacon were
added, and the diet was 20 gm. protein, 600 gm. thrice boiled vegetables, and 480
calories. This was tolerated, but on the next day (Jan. 7) 36 gm. protein and
900 calories with only 400 gm. thrice boiled vegetables (celery, spinach, and Brus-
sels sprouts) caused glycosuria. Diets of this sort or lower were continued, with
almost continuous slight glycosuria. The carbohydrate intake shown by the
graphic chart Jan. 21 to 28 was in the form of caramel, which was tolerated in
quantities of IS to 30 gm. daily without glycosuria. Under these low diets the
body weight gradually fell, while the strength slightly increased and the ferric
chloride reactions became pale or negative. With the progressive improvement
it became possible early in Feb. to raise the diet to approximately 68 gm. pro-
tein and 1400 calories, 250 of these being alcohol calories. In the latter part of
Feb. the intake could be markedly increased, and in Mar. and Apr. the diet ran
as high as 80 to 90 gm. protein and 2500 calories (of which 250 were alcohol)
and 200 to 300 gm. thrice cooked vegetables. With this there was a fast-day
weekly. During Feb. the patient was allowed out of bed, and in Mar. he was
encouraged to make trips from the hospital for exercise. On Mar. 12, he was
able for the first time to walk a mile. Thereafter he took steadily increasing
exercise, and high diets were allowed not only to build up strength but also to
support muscular activity. Glycosuria was limited to bare traces demonstrable
only in certain fractional specimens of certain days and not in the mixed 24
hour urine. But at the beginning of Apr. a more definite glycosuria appeared,
also the blood sugar on Apr. 3 was 0.27 per cent. Accordingly food was stopped,
making the diet on this day less than 900 calories. On Apr. 4 only 130 cc. whisky
were given, and on the following days only whisky and soup. After these 3
days of practical fasting, the blood sugar was down to 0.1 per cent.

Then on Apr. 7, 5 gm. carbohydrate were given in the form of green vege-
tables, and these without other food were increased on the following days, until
50 gm. carbohydrate were taken without glycosuria (Apr. 10). On Apr. 12, the
high protein-fat diets with weekly fast-days were resumed, with resultant hyper-
glycemia, so that on Apr. 28 the blood sugar was 0.31 per cent. Accordingly 4

CASE RECORDS 269

days of absolute fasting were imposed, followed by a carbohydrate tolerance test
in regular form. The tolerance was found to be almost 100 gm. carbohydrate.
Up to May 20 diets were given below 1500 calories, containing 10 to 15 gm. car-
bohydrate. Then, because of glycosuria and hyperglycemia, carbohydrate was
omitted, but resumed again in June. By this time the patient could tolerate a
daily ration up to 80 gm. protein, 20 gm. carbohydrate, and 2000 calories, with
an absolute fast-day each Sunday. He was dismissed on such a diet, with the
carbohydrate diminished to 15 gm. The urine was normal, and the clinical
condition, aside from the emaciation, was good.

Acidosis. — The excretion of as much as 2.75 gm. ammonia nitrogen at first in-
dicated a rather marked acidosis, but dangerous symptoms were never present.
An intense ferric chloride reaction was present, and there was the usual odor of
the breath, but no dyspnea. As shown in the graphic chart, t|he ammonia rap-
idly fell during the initial fast. On Dec. 8 the ammonia nitrogen was 0.74 gm.
and the ferric chloride reaction was negative. Protein-fat diet, together with
the use of whisky, sent the ammonia nitrogen up to 1.68 gm. on Dec. 11. It
then fell promptly when the diet was reduced, and beginning Dec. 18 rose still
higher as the diet was made higher than before, reaching the summit on Dec. 21.
It again fell with reduction of diet, and even on the large carbohydrate-free diets
of Mar. and Apr. never returned to the former height. The ferric chloride reac-
tion became consistently negative in the period Jan. IS to 28. Many of the
traces indicated elsewhere were only tinges of color in individual fractions of the
24 hour specimens. For the sake of improvement ia strength, the above men-
tioned high diets of Mar. and Apr. were continued in spite of the well marked
ferric chloride reactions which they produced, with the idea that as long as the
tolerance was rising and the urine kept sugar-free, the mUd acidosis could be left
for disposal in the future. The curve of the blood bicarbonate, beginning Jan. 24,
also reveals the slight chronic acidosis. Alkali was seldom used. 15 gm. sodium
bicarbonate were given on the day of admission; also, toward the close of the initial
fast, 15 gm. on Dec. 2 and 3, and 5 gm. on Dec. 4, all as precautionary measures.
On Feb. 19, 10 gm. bicarbonate left the urine slightly acid. On Feb. 20, 20 gm.
turned the urine alkaline. Likewise the carbon dioxide capacity of the plasma
rose within the lower normal limit on Feb. 20 for the first time. It was still
approximately at this level on Feb. 22, following the fast-day of Feb. 21. But
then, because of the high fat diet or merely loss of the administered alkali, it fell
steeply to the lowest value yet observed; namely, 40 per cent on Feb. 24. It
promptly rose agaui on Feb. 25 without the use of alkali, and the tendency now
to remain closer to the normal level may be interpreted as one indication of the
general improvement. The fasting and minimal diets Apr. 3 to 11 brought
another sharp fall, but thereafter on Apr. 15 it rose still higher than before.
Again the fasting of Apr. 29 to May 2 brought another sharp drop below normal,
followed by a rising tendency; so that on a moderate total diet containing a small
quantity of carbohydrate the blood alkalinity at the last determination on June

270 CHAPTER in

24 was fully normal and higher than at any point in the entire previous record.
Correspondingly the ammonia output was within normal limits, and the ferric
chloride reaction in the urine had become consistently negative.

Alcohol. — ^Whisky was given in moderate quantities for the sake of keeping up
strength. It seemed clearly beneficial for this purpose. The patient felt less
well with larger doses, and it was never pushed to any high quantity. There is no
evidence of any effect ia clearing up acidosis. After Apr. 7 alcohol was (as in
all cases when possible) discontinued altogether. The clearing up of the acidosis
progressed uniaterruptedly, so that the impression is created that the alcohol
was without influence in this regard.

Blood Sugar. — A solitary determination on Jan. 25 showed a strictly normal
value of 0.1 per cent. No fiulher analyses were made until Apr. 1, when the
level was 0.145 per cent. The diets had been high, and at this time were raised
to the maximum; namely, almost 3000 calories on Apr. 2. The result was glyco-
suria, with hjrperglycemia of 0.27 per cent on Apr. 3. The subsequent 3 days
of fasting and alcohol brought the blood sugar down to 0.1 per cent on Apr. 6.
On Apr. 8, with carbohydrate feeding, it rose promptly to 0.182 per cent without
glycosuria. On the ensuing carbohydrate-free diet of 2200 to 2S00 calories it
rose steadily higher, up to 0.312 per cent on Apr. 28. 4 days of fasting restored
a normal value of 0.118 per cent in the plasma on May 3. It will be noticed
that in these periods of feeding and fasting the rise and fall of the blood sugar
and body weight were parallel. A small amoimt of carbohydrate in the diet
from May 11 onward was in excess of the true tolerance, as indicated by the rising
blood sugar, which reached 0.20 per cent on May 18; and though it still rose to
0.232 per cent on May 22, the omission of carbohydrate and a fast-day on May
23 brought a fall to 0.138 per cent on May 24. With restoration of carbohydrate
in the diet the blood sugar again rose, reaching 0.2 per cent on Jime IS. In gen-
eral, it is seen that the hyperglycemia is a more delicate index of the tolerance
than the glycosuria. On the other hand, it is by no means a sole criterion of the
condition or progress. The normal blood sugar of Jan. 25 was the result of 2
months of semistarvation. At later periods the blood sugar was higher, though
the patient's diabetes was definitely improved, in the sense that he could tolerate
more of all classes of food and more easily remain free from both glycosuria and
ketonuria. In other words, an identical diet would doubtless have caused greater
hyperglycemia in Jan. than in June. The hyperglycemia at the time of discharge
was the one noticeably abnormal feature in the condition, but, as the subsequent
experience showed, it could be borne by such a patient without preventing the
general tendency to improvement under treatment.

Body Weight. — ^The patient, whose normal weight was 75 kg., entered weighing
44.2 kg., i.e., 59 per cent of his normal weight, or a loss of 30.4 kg. During
fasting his weight rose by water retention, the sodium bicarbonate of Dec. 2 and
3 probably being responsible for the summit of the weight curve on Dec. 3. The
rise of weight was accompanied by well marked edema of the ankles. The patient

CASE EECOEDS

271

stated it had been present at former times to a still greater extent. With the
continuous undernutrition there was a sUght progressive fall in weight, the lowest
point being 39.8 kg. on Feb. S. Thereafter with the increased diets the weight
steadily rose, so that the patient was discharged on June 28 at precisely his
entrance weight of 44.2 kg.

Nutrition. — ^The salient feature is the degree of undernutrition imposed upon a
patient already extremely emaciated and weak. The patient himself had not
expected to hve. Notwithstanding this state of weakness, he not only with-
stood a 6 day fast successfully, but also bore 2 months of radical undernutrition
thereafter.

From Nov. 30 to Feb. 2 the following calculation can be made.

65 days.

Per day
(average).

Per day
per kg.*

1655.8 gm.
264.9 "
23362
28249
51611

25.40 gm.
4.07 "
359.4
434.6
794.0

5.80 gm.
0.09 "
8.00

Total nitrogen in diet

Alcohol calories

Food "

10.00

Total "

18.00

* On 44 kg. weight.

The case at first seemed hopeless, with the combination of emaciation and
weakness on the one hand and inabUity to tolerate a living diet on the
other. The extreme restrictions necessary for controlling the diabetes were
rigidly carried out, and the unmistakable gain in strength along with loss of
weight under these conditions was the most surprising feature. At dismissal,
with the identical body weight as at entrance, the physical condition was trans-
formed. The man had come as a helpless bedridden invahd supposedly at the
point of death. At discharge he was stiU very thin, and strangers regarded him
as having tuberculosis or cancer, but he was able to make the trip to his home
unattended and carry his two heavy suitcases without assistance.

Subsequent History. — ^The patient resumed his business duties and also took con-
siderable daily exercise as instructed, chiefly in the form of walking. He remained
free from glycosuria and other symptoms, with continuous improvement in
strength and health, untU he committed a few minor indiscretions in diet, con-
sisting only in the addition of a few eggs and vegetables beyond the prescribed
quantity. Persistent glycosuria resulted, which did not stop on omitting aU
carbohydrate or on the routuie fast-days. He reported his condition promptly
and was advised to return to the hospital.

Second Admission. — ^The patient returned Oct. 17, 1915, weighing 45.2 kg.;
i.e., a gain of 1 kg. The glycosuria and ketonuria on his regular diet were both
rather heavy. The ammonia nitrogen was up to 1.54 gm. The carbon dioxide
capacity of the plasma was as low as 46 per cent, and the plasma sugar was 0.35
per cent. But the physical strength was still as good as at discharge, and the

272 CHAPTER in

task of treatment was far easier than before. Blood pressure 102 systolic, 82
diastolic.

After 1 week of observation on the diet which had been tolerated at the former
discharge, fasting was imposed Oct. 24 to 31. The urine was sugar-free on Oct.
30. On Nov. 1, 10 gm. carbohydrate were given in the form of green vegetables,
followed by the usual increase of 10 gm. daily, and definite glycosuria appeared
with 40 gm. carbohydrate. This may be compared with the 100 gm. tolerance
in the previous May and with the zero tolerance at the outset of treatment.

Beguming Nov. 8, a diet of 75 gm. protein, 5 gm. carbohydrate, and 1800
calories caused glycosuria. Therefore carbohydrate was omitted, and the protein
diminished to 50 gm., and total calories to 1300. This diet represented approxi-
mately 1.1 gm. protein and 30 calories per kg., but the weekly fast-days brought
the average down to approximately 0.9 gm. protein and 26 calories per kg. — a
low diet especially in view of the rather vigorous exercise which the patient was
encouraged to take. Nevertheless, the blood sugar remained unduly high and
traces of glycosuria were frequent.

Beginning Nov. 25, an attempt was made to mcrease protein while keeping
the total calories the same by subtracting an equivalent of fat. The protein was
thus gradually raised to 110 gm. on Nov. 30, the calories remaining 1300. The
blood sugar rose markedly, and glycosuria appeared with 100 gm. protein on
Nov. 29.

Beginning Dec. 12, radical undernutrition was maintained imtil Jan. 7 in
the most favorable manner possible, namely by restriction or almost complete
exclusion of fat. The protein was at first kept unchanged at SO gm. On Christ-
mas day as a special indulgence, 85 gm. protein were granted to allow the patient
to enjoy turkey. After Jan. 28 the regular protein allowance was 60 gm. Owing
to exclusion of fat, the total calories were only 300 daily up to Dec. 17. For the
week of Dec. 20 they were increased to 600 by addition of alcohol. By increase
of protein and fat they were brought up to 1000 on Jan. 3 to 6. The most strik-
ing effect of the exclusion of fat was not upon the ammonia but upon the blood
sugar, which was brought well within the normal limits. Also the tolerance was
improved, so that beginning Jan. 8 the patient was able to tolerate a diet of 70
gm. protein, IS gm. carbohydrate, and 1900 calories. The body weight was
down to 43.2 kg., or 1 kg. less than at the former discharge, but the strength
and general condition were better than at any former time. The patient was
discharged on Jan. 18 to resume his business in his home town.

Acidosis.— As mentioned, the ammonia output and carbon dioxide capacity of
the plasma indicated a slight acidosis on admission. The high point of the am-
monia nitrogen at 2.5 gm. on Oct. 26 does not necessarily mean that the ammonia
rose on fastmg. The only previous determinations had been on Oct. 17 to 18,
and it is possible that toward the close of the week of feeding the ammonia was
higher than on Oct. 26. After this date the ammonia fell sharply, and reached
a still lower point with the carbohydrate tolerance test on Nov. 3. With protein-

CASE RECORDS 273

fat diet it again shot up to 2.5 gm. N on Nov. 11. On Nov. 15, following a
fast-day, it was again found at the lower level of 0.7 gm., rising again with pro-
tein-fat diet. But as this diet was only 1300 calories, the ammonia remained de-
cidedly lower than it had been with 1800 calories. Thereafter the curve slopes
gradually down to the normal output of 0.35 gm. at discharge. The ferric chlo-
ride reactions were easily cleared up and remained negative. The carbon dioxide
capacity rose with fasting to the lower normal limit on Oct. 30. With a slight
fluctuation it came safely up within normal values with the carbohydrate tol-
erance test on Nov. 5. With the 1800 calory diet composed chiefly of fat, it fell
steeply below the lower normal level on Nov. 10. Thereafter it fluctuated above
and below the lower normal limit. The highest value, namely 71.6 per cent,
was shown on the fast-day of Dec. 12. At discharge it was exactly at the lower
normal limit of 55 per cent.

Blood Sugar. — ^At admission the plasma sugar was 0.35 per cent, and with con-
tinuance of observation diet reached 0.43 per cent on Oct. 21, and 0.44 per cent
on Oct. 22. It fell sharply on fasting, so that on the second fast-day (Oct. 25)
it was down to 0.17 per cent. The succeeding fluctuations are not explained.
The behavior for several days is so bizarre that the accuracy of some analyses is
called into question. But on Oct. 29, the day when glycosuria ceased, the
plasma sugar had fallen to 0.23 per cent. With the carbohydrate tolerance test
it rose to 0.325 per cent on Nov. 4. On Nov. 8, following the fast-day of Nov. 7,
it was down to 0.2 per cent. The diiet of 1800 calories caused a rise to 0.44 per
cent on Nov. 11. Thereafter, with the diet of 1300 calories, it wiU be seen that
the sugar tended to be up during the week and down on the morning after the
weekly fast-day, but hyperglycemia was continuous. The rigorous undernu-
trition beginning Dec. 12 was what definitely brought the blood sugar down
within normal limits. On the hberal diet with 15 gm. carbohydrate at discharge, '
hyperglycemia again resulted to the extent of 0.16 per cent plasma sugar. This
was the one unfavorable feature at discharge.

Exercise. — Beginning Nov. 11, the patient was exercised daily to the point of
exhaustion, being required to walk up and down 8 flights of stairs 6 times daily,
walk 3 or 4 miles, and toss a 6 pound medicine ball for half an hour daily. With
this amount of labor the diet of 1300 calories was definite undernutrition, yet
neither the body weight nor the blood sugar diminished very perceptibly. The
clinical condition was rather unfavorably affected, however, and the patient was
tired and exhausted from the prolonged exertions. Therefore, beginning Dec. 12,
he was kept in bed during the period of marked undernutrition, and gained in
well-being by reason of the rest. With the higher diets which began in Jan.
he was allowed to take moderate exercise, and was advised to continue this at
home. -

Subsequent History. — ^The patient remained at home from Jan. 18, 1916, to
June 25, 1917, and during this time missed only 6 days from his regular busi-
ness, in consequence of slight additions to the diet, or on two occasions because

274 CHAPTER m

of colds. The weight was up to 48.1 kg. One of the colds mentioned then caused
a setback requiring slight reduction of diet, so that during the summer the
weight was approximately 46 kg. On Jan. 13, 1917, at the patient's request,
he was allowed to diminish his diet from 1900 to 1500 calories, which he said
satisfied him, and on this basis he omitted the weekly fast-days. On May 31,
1917, a telegram was received from the patient stating that he had yielded to a
holiday temptation to eat strawberry shortcake and pie, and was showing heavy
glycosuria in consequence. He was instructed to fast himself sugar-free, and
did so successfully. On June 13, he accidentally increased his diet by 300 calories,
and showed a trace of sugar in consequence.

Third Admission. — On June 25, he appeared unexpectedly at the hospital,
stating that he had decided to travel for a change, and had dropped in to report,
and to stay for examination if desired, especially as he was now finding trouble in
remaining sugar-free after his recent indiscretions. The weight was 45.5 kg.
Although slight glycosuria and ketonuria were found present, the condition was
now very simple from the therapeutic standpoint, and the opportunity was em-
ployed to carry out a test of the effect of fat feeding, as described in Chapter VI.

Remarks. — The heavy Upemia which was such a striking feature of this case at
the outset would have been an interesting feature to study chemically if
circumstances had permitted. Presumably it was responsible for the remark-
able yellow color of the patient, but this color persisted with Uttle diminution
long after the blood plasma had become entirely clear. This color of the skin
was very well marked at the second admission. By the third admission it had
almost entirely disappeared and the complexion had begun to look normal.

Also, though the weight was only 1.3 kg. more than at the original admis-
sion, the face and bearing were different. The patient was stiU excessively
thin, but with the change in facial expression, complexion, and energy of move-
ment, strangers no longer looked upon him as a sick man, and he behaved in all
respects like a normal person. The outcome is therefore a satisfactory one un-
der the circumstances. The diabetes seems to be under control, and any mani-
festations appearing can in each instance be cleared up more easily and quickly
than on former occasions — one indication of favorable progress. The diabetes
was genuinely severe, as demonstrated by the prolonged mtolerance of food and
by the enture history. The heavy hpemia may probably be included among the
symptoms of severity. Death must have resulted within a brief period in the
absence of radical treatment. The ultunate prognosis in a case at this age is
generally better than in younger persons, and the tendency to improvement
seems more permanent and genuine.

This patient furnishes another example of the absence of any perceptible
spontaneous aggravation in a very severe case of diabetes under observation for
2i years; but the possibility of downward progress due .to chronic pancreatitis may
yet have to be considered. The patient describes himself as feeling better than
for many years past. He carries on his work successfully and enjoys life. Fur-

CASE RECORDS 275

thermore, he has had no more attacks of cold and grippe than at periods before
his diabetes, and no greater difficulty in recovering from them. Notwithstanding
the still low tolerance, the outlook at the present time appears favorable for some
time to come.

CASE NO. 25.

Female, married, age SO yrs. Austrian Jew; housewife. Admitted Nov. 28,
1914.

Family History. — Parents lived to old age. Four brothers and two sisters are
well. No heritable disease in family. Patient has been married 28 years. Had
six children and later three miscarriages. One child died of diphtheria, another
in an accident; the other four are well, aged 13 to 26 years.

Past History. — ^Healthy life. Patient came to United States from Austria at
age of 28 and has lived in fairly hygienic surroundings. Erysipelas, in 1912
and again in Jan., 1914, was practically the only infection. Venereal disease
denied, although 3 years ago a general eruption is said to have appeared over the
whole body and disappeared after a few days. 8 or 9 years ago, left-sided hemi-
plegia occurred suddenly and improved gradually within 6 months. A second
stroke occurred in Jan., 1914. Edema of ankles has been noticed during past 2
years. Habits have been regular. No alcohol or other special indulgence.

Present Illness. — 3 years ago a routine urine examination revealed sugar.
Since then one test every month has always shown sugar but never acetone. For
2 years past there has been dyspnea and palpitation on slight exertion, so that
she has been practically confined to her house. Dyspnea also has frequently
made her unable to sleep lying down at night, so that she has had to stay in a
chair. No polyphagia, polydipsia, or polyuria. She has been on a lax anti-
diabetic diet of protein, fat, and green vegetables unrestricted in quantity, and
two roUs and a slice of bread daily. Weight 3 years ago 211 poimds, now 186
pounds. 1 week ago the patient went to a hospital clinic, and was ordered to
stop carbohydrate. Thereafter she began steadily to feel worse and has shown
a progressively increasing stupor during the past few days, with nausea which
has led to vomiting during the past 2 days.

Physical Examination. — A large framed, obese woman lying in bed in a stu-
porous condition and irrational when roused. The odor of the breath is partly
sweetish, partly foul. Some dyspnea is present, but seems of a panting and ner-
vous type rather than Kussmaul air-hunger. The face is sHghtly edematous and
pits on pressure. Exophthalmos and apparent photophobia. Pupils react to
light and accommodation. No jaundice. Pyorrhea and receding gums. Tonsils
slightly enlarged. Signs of slight left-sided paresis. Thyroid lobes hard and
definitely palpable; isthmus not felt. Lymph nodes not enlarged. Some bron-
chitis and emphysema. Cardiac dulness extends 4 cm. to right of midstemal
line and 13 cm. to left in fifth interspace. Soft systoHc blowing murmur at apex.
Aortic second sound markedly accentuated. Walls of radial arteries not pal-
pable. Abdomen obese and flaccid, negative to examination. Knee and Achilles

CASE RECORDS 277

On Dec. 9, this was increased to two eggs and 20 gm. butter; and though no
vegetables or other sources of carbohydrate were given, a trace of glycosuria
appeared, and continued when one egg was given on Dec. 10 and two eggs on
the subsequent days. The protein intake ranged from 15 to 46 gm. and the
total calories averaged well below 1000, even including alcohol, until on Dec.
17 and 18 a diet of eggs and olive oil was given, without vegetables or whisky, rep-
resenting 44 to SO gm. protein and 1900 to 2000 calories. Such diets sufficed to
maintain a continuous glycosuria. This cleared up when nothing but two eggs
was given on Dec. 20. But on Dec. 21, the feeding of only 80 gm. asparagus,
containing 2.2 gm. carbohydrate, caused a trace of glycosuria. To clear this up
3 fast-days with whisky were necessary, on Dec. 24 to 26. Then, on Dec. 27,
the feeding of two eggs and 500 gm. thrice boiled vegetables brought back a
decided trace of glycosuria. After omission of all vegetables, the frequent traces
of glycosuria still continued on low diets Umited to eggs, olive oU, soup, and
coffee, none of these diets containing more than 52 gm. protein and 1300 to 1950
calories. The subsequent treatment represented a continuance of such under-
nutrition. The principle was adopted of giving protein to conserve body nitro-
gen and alcohol to assist weakness, while keeping fat and calories at a very low
figure and compelling the patient to burn off her body fat.

She remained almost without appetite, and on Feb. 4 mentioned being hungry
for the first time. The ferric chloride reaction was much diminished and the
occasional traces of sugar were only very faint reactions in fractional specimens
on certain days. The patient was desirous of continuing treatment at home, and
as all immediate danger was over and the one necessity was merely a continuance
of undernutrition, she was allowed to go out on a diet of 1250 calories, 350 of which
were alcohol. She was instructed to take a fast-day whenever sugar appeared and
once every 2 weeks if it did not appear. She was also warned against constipa-
tion and was encouraged to take exercise. At the time of discharge she was be-
ginning to take short walks, which tired her considerably. Aside from the
weakness, symptoms were absent and she felt well.

Second Admission. — Feb. 11, 1915. The patient was readmitted 5 days after
discharge. She had followed her diet but had had no bowel movement during
this time. The former symptoms recurred in milder form, and she was drowsy and
vomiting occasionally when received. The glycosuria was 0.6 per cent, and the
ferric chloride reaction was heavier than at discharge. A low ammonia value
was found on Feb. 13 after 3 days of fasting. There was no albuminuria, but the
face and ankles were again puffy and pitted on pressure. Blood pressure 170
systolic, 110 diastolic. 30 gm. sodium bicarbonate may have played a part in
the edema. The treatment was carried out on the same lines as before, the
most important feature being the purgation with 2 gm. compound jalap powder
daUy, which yielded the same enormous stools as before. The first 12 days in
hospital, up to Feb. 23, represented almost continuous fasting. 200 calories of
alcohol were given almost daily during this entire period in hospital. The acute

278 CHAPTER ni

sj^nptoms passed off easUy. The food tolerance was obviously higher than be-
fore, and a more liberal diet was gradually built up, finally reaching 83 gm. pro-
tein and 2000 calories at the time of discharge on Mar. 25. Traces of glycosuria
were frequent but easily controDed. Albuminuria was constantly present after
the initial days. The blood pressure on Feb. 16 was 205 systolic, 130 diastolic;
on Feb. 20, 185 systoKc, 140 diastolic. The patient was feeling stronger and in
better condition in aU respects than at the former discharge. The diet pre-
scribed to be followed at home was carbohydrate-free, containing 100 gm. pro-
tern (1.5 gm. per kg.) and 1500 to 1750 calories (23 to 26 calories per kg.). It
was considered probable that she could remain free from glycosuria on this diet,
and if so the shght persisting ketonuria would gradually take care of itself.

Subsequent History. — Reports showed that the patient remained sugar-free
and continued to gain in strength and well-being at home. On May 21, her son
telephoned that she had had some sort of stroke during the night and an ambu-
lance surgeon had diagnosed pulmonary edema. Her death occurred the same
day, and the certificate of the coroner's physician assigned chronic nephritis as
the cause. There was no sugar in the urine at any time.

Acidosis. — The acidosis was never quantitatively high, and the coma was
atypical in character. There was the familiar history of onset shortly after
exclusion of carbohydrate from the diet, but constipation seemed to be a more
important factor. More complete analyses of blood and urine would have been
valuable had they been possible at this time. Along with the general food in-
tolerance, the ammonia nitrogen was slow in reaching normal limits, but at the
first discharge was down to about 0.56 gm. At the second admission the figure
0.28 gm. ammonia nitrogen was obtained after 3 days of fasting; there might weU
have been a much higher ammonia earlier in the attack. Such a possibility is
strengthened by the rise to almost 2 gm. ammonia nitrogen with the diet of only
1100 calories on Feb. 26. The ferric chloride reaction became pale toward the
close of each stay in hospital, and accordingly no further attention was paid to
it, since with continuance of undernutrition and freedom from glycosuria it was
certain to become negative.

Estimations of the carbon dioxide capacity of the plasma were made begin-
ning Feb. 23, and confirmed the tendency to chronic acidosis. Inasmuch as so-
dium bicarbonate had been used rather liberally in the opening days of each
hospital period and had presiamably raised the blood alkalinity, there is some
ground for supposing that such analyses if made during the stuporous attacks
would have indicated a true acidosis coma. Subsequently, in the absence of
bicarbonate, the carbon dioxide capacity of the plasma in Feb. and Mar. ranged
between 45 and 53 per cent. There is no evidence that alkali dosage would
have altered the subjective condition, which was good; and the fundamental acido-
sis process could be influenced only by continuance of the undernutrition pro-
gram as adopted, whereas the giving of alkaU would only have masked the lab-
oratory indications.

CASE RECORDS

279

Blood Sugar. — Only one determination was made. This was 0.118 per cent
before breakfast on Mar. 22. There is no evidence of a renal glycosuria, but on
the other hand a continuous h)Tperglycemia seems excluded, notwithstanding
both diabetes and nephritis.

Undernutrition. — During the initial fast, Nov. 29 to Dec. 7, inclusive, the
patient lost 94.3 gm. nitrogen in the urine. Dec. 8 to 11 the ingestion of 7.5 to
15 gm. protein daily left the nitrogen output at its minimal fasting level of about
8 gm. daily. The degree of undernutrition in the first period in hospital is shown
by the following calculations:

Total nitrogen output

Protein intake

Nitrogen " (protein -^ 6.25).
" deficit (output— intake)

13 days.

127.19 gm.
46.70 "
10.35 "
116.84 "

Per day
(average).

9,78
2.60
0.79
8.99

70 days.

Per day
(average).

Alcohol calories . ....

18518
25701
54219

264.5

Food "

495 7

Total "

760 2

Owing to the clinical condition it was not feasible to weigh the patient uritU
Dec. 6, when the weight was 76 kg. The obesity was diminished as rapidly as
feasible by undernutrition, while the body nitrogen was protected as far as pos-
sible by allowing protein in quantities just short of producing any considerable
glycosuria. Fat was the element which was mainly eliminated from the diet,
and general undernutrition and the burning off of body fat was regarded as the
most important therapeutic measure. At the first discharge the weight was 68.4
kg., and at the second admission and discharge respectively it was approximately
66 kg.; i.e., 10 kg. below the first weight. Strength, well-being, and food toler-
ance had risen in proportion to the fall in weight.

Remarks. — The importance of emptying the bowels when there is impending
coma, especially in certain cases, has been pointed out by former writers. In
this instance it seemed the most important therapeutic measure. Though there
were chemical indications of acidosis as above noted, the urine was easily
made alkaline and the actual quantity of acid formed was evidently not great.
A feature of therapeutic interest is the fact that a very obese patient already
suffering from acidosis with nausea and vomiting came through safely with
simple fasting. There is no evidence of any specific value of the alcohol used.
The danger of increased acidosis from fasting in patients of this type is obviously
to be borne in mind; but a coma which comes on with feeding can generally be
treated by fasting. The reduction of the excessive body weight was beneficial

280 CHAPTER ni

from every standpoint. Judging by the threatened coma and subsequent almost
complete intolerance of food, the case might be called extremely severe, but with
mere continuance of undernutrition sufficient to bring the excessive weight
down to normal or slightly below the average normal, the condition would almost
certainly have stood revealed in its true light as one of fairly mUd diabetes. For
this reason, with falling body weight and rising general health, the traces of
glycosuria and ketonuria were ignored to an extent never ventured in younger
patients. Also this patient's nephritis was far more dangerous to her than her
diabetes. The existence of nephritis in no way interfered with the treatment of
the diabetes. Though the blood pressure diminished as the ordinary conse-
quence of hospital care, there is no indication that the nephritis was improved
by the diabetic treatment. It so happened that death came early from some
embolic or other accident, but the case nevertheless Ulustrates the benefit of
proper treatment of diabetes even in the presence of complicating conditions.

CASE NO. 26.

Female, age 14 yrs. American; schoolgirl. Admitted Dec. 7, 1914.

Family History. — No diabetes in family. Mother's mother died of cancer,
and mother's grandmother of "dropsy." Several more remote relatives died of
tuberculosis. Patient's father is healthy, the mother nervous but fairly strong.
There have been no other children and no miscarriages.

Fast History. — Girl has been healthy though rather nervous. Measles at 3,
chicken-pox at 4, mild whooping-cough at 5. She began school at 6th year, was
bright and studious but not overworked. Ate large quantities of candy. Al-
ways constipated. Fairly normal menstruation began at 12. For about 2 years
before the present illness there was frequent twitching of face, limbs, and trunk
during sleep. No such movements when awake.

Present Illness. — In Feb., 1913, the patient had an attack of vomiting after
eating heavily, and for a few days was nervous and without appetite. During
the following 3 weeks polyphagia, polydipsia, and polyuria were noted, also
weariness and sleepiness. Strength then failed progressively until she became
too weak to dress herself. A physician consulted in Mar. diagnosed diabetes and
prescribed carbohydrate-free diet. On this the patient remained sugar-free until
June, but lost weight even though bread and potatoes were gradually added to
diet. Glycosuria then reappeared, but remained absent from June to Dec. on
carbohydrate-free diet. It then became persistent, and a trip was made to
consult a specialist, who placed the patient in a hospital for 2 weeks and allowed
only small quantities of carbohydrate-free food. Glycosuria ceased but keto-
nuria persisted, and all symptoms recurred promptly on returning home. The
family physician then allowed an abundance of carbohydrate. The subsequent
symptoms have been the usual loss of weight and strength, and falling out of much
of the hair. Menstruation ceased with the first period after the onset of diabetes.

CASE RECORDS 281

Physkal Examination. — A tall, emaciated, nervous appearing girl, without
acute distress. Teeth in good condition. Tonsils not enlarged. No lymph
node enlargements. Skin dry. General physical examination negative. Right
knee jerk present, left not obtained. Achilles jerks lively. Blood pressure 105
systolic, 70 diastolic.

Treatment. — ^The glycosuria for 16 hours following admission was 44.5 gm.
On Dec. 8 to 10, under an observation diet of 30 to 65 gm. protein, 3 to 10 gm.
carbohydrate, and 900 to 1300 calories, the urine contained 6.8 to 14.3 gm. sugar
and showed heavy ferric chloride reactions. Fasting was begun Dec. 11, with
200 calories of alcohol daily. Glycosuria was absent in 24 hours. 140 gm. thrice
cooked vegetables were allowed on Dec. 13, 5 gm. carbohydrate in the form of
green vegetables on Dec. 14, and 9 gm. carbohydrate on Dec. 15. A trace of
glycosuria appeared. Nevertheless the vegetables were increased, up to 44 gm.
carbohydrate on Dec. 17, then diminished while two or three eggs were added.
With this continuance of undernutrition the trace of sugar cleared up. On Dec.
26 a diet of 51 gm. protein, 9 gm. fat, and 1200 calories caused another trace of
glycosuria, which cleared up with the fast-day of Dec. 27. Alcohol was discon-
tinued on Jan. 9. It was still given on fast-days to the extent of 200 calories,
up to Feb. 21. In early Jan., diets of approximately 40 gm. protein, 6 gm. car-
bohydrate, and 1000 calories twice caused slight glycosuria, which later cleared
up, and at the end of the month a diet as high as -80 gm. protein, 16 gm.
carbohydrate, and 1700 calories was borne without glycosuria. An attempt
on Jan. 30 and 31 to raise the carbohydrate to 25 gm. resulted in gly-
cosuria, checked by the routine fast-day of Feb. 1. In the succeeding week the
diet was further increased until on Feb. 5 to 6 glycosuria resulted from 90 gm.
protein, 30 to 40 gm. carbohydrate, and 2400 calories. Thereafter still higher
diets were tolerated, but on Feb. 27 glycosuria was produced by 84 gm. pro-
tein, 50 gm. carbohydrate, and 3000 calories. Not only the laboratory findings
but also the weakness and nervousness which were the essential complaints were
improved. Also, on admission there had been a marked albuminuria with
casts, but albumin gradually diminished to a trace and casts were absent. The
patient was discharged on Mar. 6, 1915, on a diet of 25 gm. carbohydrate, 75
to 80 gm. protein (2.5 gm. per kg.), and 2400 calories (almost 80 per kg.). The
regular weekly fast-days reduced the average to approximately 64 gm. protein
and 2100 calories. The prescribed diet was thus below what she had proved
able to tolerate.

Acidosis. — This was at no time threatening. The ferric chloride reaction
diminished as usual and became negative with the low diets of mid- January.
It will then be noted that increase of the total diet brought back well marked
ferric chloride reactions, even though carbohydrate was decidedly increased at
the same time.

Body Weight. — ^This was 31.2 kg. at admission. The undernutrition treat-
ment brought it down to its lowest point of 27.2 kg. on Jan. 26. Thereafter the

282 CHAPTER rn

higher diets produced a rise in weight, so that at discharge it was 30.7 kg.; i.e.,
0.5 kg. less than at admission.

Subsequent History.— The diet was faithfully followed. A few traces of glyco-
suria required a slight diminution of the carbohydrate allowance. On one occa-
sion a trace of glycosuria followed excitement due to having seen a woman run
over by a street car. The physical and psychic conditions remained good and
the patient enjoyed hfe and kept herself interested in various occupations not
involving exertion. Nevertheless, she tended to lose slightly in weight instead of
gaining. Menstruation did not return, but none of the former symptoms of
diabetes was present.

Second Admission. — Oct. 4, 1915, the patient returned to the hospital by
arrangement, for purposes of observation and for testing the effect of exercise.
Height 156.2 cm. Weight 28.8 kg.

The urine was stiU sugar-free, but showed a trace of ferric chloride which
disappeared with a single fast-day on Oct. 5. A tolerance test was then be-
gun in routine manner with 10 gm. carbohydrate in the form of green vege-
tables on Oct. 6. A trace of glycosuria appeared with 130 gm. carbohydrate on
Oct. 19, and persisted with the same intake the next day and with increased in-
take on the following days, notwithstanding the introduction of exercise at this
point in the attempt to raise tolerance. After the clearing up of glycosuria by a
sharp reduction of food on Oct. 24 to 25, a diet was gradually buUt up, with the
usual weekly fast-days. In the week of Nov. 22, a ration of 55 gm. protein, 15
gm. carbohydrate, and 2200 calories was tolerated without glycosuria, but with
ketonuria. With the same protein and carbohydrate, an increase of fat to 2400
calories in the following week brought on well marked continuous glycosuria,
and the damage thus done resulted in a continuance of glycosuria and ketonuria,
notwithstanding a sharp reduction of diet in the succeeding week (Dec. 6 to 11).
Low nutrition beginning Dec. 12 was continued throughout the remainder of the
stay in hospital. From Dec. 15 to Jan. 22, the protein was kept at 60 gm. daily.
The calories at first were 1200, but beginning Jan. 3 were diminished to 850.
Though all carbohydrate was omitted at the same time, this diminution in total
calories brought a complete clearing up of the ferric chloride reaction. Begin-
ning Jan. 24 another carbohydrate tolerance test was made. The assimilation
was found to be 140 gm., a gain of 20 gm. over the previous test. The patient
was discharged Feb. 26 on a diet of 30 gm. carbohydrate, 60 gm. protein (2.26
gm. per kg.), and 1000 calories (nearly 36 calories per kg.). This was reduced
one-seventh as usual by the regular fast-days, making the average daily intake
approximately 1.9 gm. protein and 33 calories per kg.

Acidosis. — The most striking feature is that well marked ferric chloride reac-
tions were produced by high calory diets in every instance, irrespective of whether
these diets contained carbohydrate. On lower diets suited to the patient's actual
tolerance there has been no difficulty in keeping this test continuously negative.
The ammonia excretion is also kept at a low level. The carbon dioxide capacity

CASE RECORDS 283

of the plasma tended to remain near or below the lower normal limit, but was
within normal limits at the time of discharge.

Blood Sugar. — Though this must have been high with the glycosuria resulting
from the carbohydrate test of Oct., yet, as usual when hyperglycemia is pro-
duced only by carbohydrate, it fell quickly, for on Oct. 25, after 2 days of low
diet, it was down to 0.13 per cent. It promptly rose to 0.26 per cent in the
plasma on the next day with continuance of a diet of 1200 calories and 15 gm.
carbohydrate. On the morning of Nov. 1, following the fast-day of Oct. 31, it
was down to the former approximately normal level. The curve ran similarly
through Nov., with hs^perglycemia on feeding and lower values following fast-
days, but with a general upward tendency. The diet up to 2400 calories, ending
Dec. 4, had produced such injury that the reduction to 1500 calories did not
prevent the occurrence of the highest blood sugars of the series; e.g., 0.32 on
Dec. 9 and 0.29 on Dec. 11, with glycosuria. This was one of the reasons for the
ensumg sharp reduction of diet. After 2 days of fasting on Dec. 12 and 13, the
sugar in the plasma on the morning of Dec. 14 was down to 0.155 per cent, and
in the whole blood down to 0.125 per cent. Thereafter the curve ran nearly
within normal limits, except for the sharp terminal rise on Feb. 25 to 0.224 per
cent. This occurred on 40 gm. carbohydrate, and the patient was sent home
with only 30 gm. carbohydrate in the diet. .

Body Weight. — At the second admission this was 2 kg. less than at the pre-
vious discharge, and at the second discharge it had been brought down still
lower. The net result of treatment from the first admission to the second dis-
charge was a reduction of weight by 4.9 kg. At home the patient's weight has
been constantly reported as approximately 60 pounds; i.e., about 27 kg., or 4
kg. less than at her first admission. There has been no appreciable growth in
height, but the patient was already almost as tall as her mother. She is notice-
ably emaciated, but the graphic chart well illustrates that every gain of weight
brought on glycosuria and acidosis. In order to Uve, the patient must keep her
weight down. It is not only inadvisable but impossible to force the weight up,
for any diet exceeding her tolerance as respects food and weight wiU quickly
bring on active diabetic symptoms, which of themselves would lead to loss of
weight.

Exercise. — The second period in hospital was devoted largely to a clinical test
of exercise in this patient. During the carbohydrate tolerance test in Oct. she
was kept at rest until the first trace of glycosuria appeared. She was then ex-
ercised to the limit of her strength, chiefly by climbing stairs and walking, also
by roller-skating and tossing the medicine ball. The glycosuria did not cease,
and no gain in tolerance could be demonstrated. Subsequently high diets were
given, as stated, from the latter part of Oct. to the forepart of Dec; and the
patient, who was moderately strong, was exercised regularly to her utmost ca-
pacity in the attempt to bum off the surplus calories. The low plasma bicarbon-
ate during this time is doubtless due in part to exercise. It proved impossible to

284 CHAPTER in

prevent hyperglycemia and finally glycosuria by this means, and the ferric
chloride reaction became positive when exercise was thus taken to bum up the
fat, though on lower fat intake it was negative even without exercise. Accord-
ingly in Dec. the diet was reduced as above mentioned. Exercise was still
continued.

From Dec. 12, 1915, to Jan. 23, 1916, three influences were present, namely,
carbohydrate abstinence, undernutrition, and hard muscular exercise. Never-
theless, the absence of any noteworthy acidosis is demonstrated by all tests.
The rise of 20 gm. in tolerance shown by the carbohydrate test in Feb. is merely
what might be expected from the undernutrition treatment, and there is no
indication that the 4 months of hard systematic exercise had served specifically to
increase tolerance.

Subsequent History. — ^At the time of discharge the patient was advised to dis-
continue severe exercise and take only as much as she could enjoy. She has
foimd pleasure in spending much of her time in walking, bicycling, and various
forms of active play. What has actually been accomplished by exercise is a
decided gain in strength, general health, and happiness. The change, as com-
pared with the first admission when she was kept nearly at rest, is evident at a
glance, and friends complimented her on her improved color and appearance.
Nervousness and worry are also controlled, and she is enabled to derive some real
enjoyment from life.

Glycosuria has remained absent except for rare traces due to unintentional
excesses; e.g., traces resulted from the use of cream cheese or sugar cured ham.
By June 19 she had lost three quarters of a poxmd in weight, but this was slightly
more than regained by Sept. In the fall she undertook light school work. In
Nov. and Dec. she had two colds and showed traces of sugar several times in
consequence, so that carbohydrate had to be entirely eliminated from the diet on
some occasions. In Apr., 1917, the patient reported having finished the first year
of high school and having easily obtained the highest mark in every subject.
Her diet has been modified to consist of 40 gm. protein, 10 gm. carbohydrate, and
1000 calories. She keeps herself sugar-free without difficulty and knows how to
treat herself if accidental causes bring on traces of glycosuria.

Remarks. — This patient, when received, presented a case of juvenile diabetes
of 2 years standing and considerable severity. The subsequent treatment illus-
trates especially two points. One is the effect of exercise. The case was of
such severity that the deficiency of the pancreas could not be balanced to any
appreciable extent by improved function and activity of the muscles. Accordingly
the carbohydrate tolerance was not perceptibly improved, but the general health
was greatly benefited. Second is the question of growth and nutrition. Here
the clinical experiment was performed of taking this patient, clearing up her
condition radically by undernutrition, so that about the middle of Jan., 1915,
she was entirely free from both glycosuria and acidosis, and then making the
attempt to have her grow and develop. The diets in the latter half of the first

CASE RECORDS 285

hospital period were plarmed to this end. The weight rose, but symptoms shnul-
taneously returned. The diet at this discharge represented approximately 2.25
gm. protein and 80 calories per kg. of body weight. Fasting and modifications of
diet required by the occasional traces of glycosuria absolutely prevented gain or
growth. It is not known whether a specific diabetic deficiency also may be con-
cerned. The net result of this attempt to put on weight was, as stated, that the
patient returned to the hospital 7 months later, weighing 2 kg. less than at
discharge.

After the undernutrition represented by the Oct. carbohydrate test, the diet
was gradually built up, the weight rose with it, and the maximum of weight and
the onset of urinary symptoms coincided (Dec, 1915). Subsequently undernu-
trition diminished the weight and removed all active symptoms. It is obvious
throughout that the total diet was the essential governing factor, and the relative
proportions of protein, carbohydrate, and fat were of minor influence. The net
result to date is that the patient is alive 3 years from the beginning of this treat-
ment, and 4| years from the onset of her diabetes. There is no evidence of any
spontaneous downward progress; neither has there been any fundamental'im-
provement. The cumulative effect of slight strains and accidents may bring
bad results sooner or later. Meantime, the patient is holding her own and is
actually deriving enjoyment from Kfe and carrying on limited activities. The one
requisite is close- control of her diet.*

CASE NO. 27.

Male, married, age 42 yrs. American; clerk. Admitted Jan. IS, 1915.

Family History. — One sister died of cardiorenal disease at 23. Family his-
tory otherwise negative. Patient has been married 18 years and has one healthy
son, aged 15. Wife healthy; one miscarriage about 13 years ago.

Past History. — Healthy life. Good hygienic surroundings. Measles and
chicken-pox in childhood; mild diphtheria at 8; mumps at 18, complicated by
unilateral orchitis. At about 20 there was an attack of jaundice with clay-
colored stools lasting 2 or 3 days. At 26 one attack like acute appendicitis,
which passed off under ice applications in a hospital. There have been indefi-
nite minor attacks since. At 27 patient had fever every night for 28 days, with
one hard chill at the end; then given medicine by family physician and has had
nothing like malaria since. Occasional sore throats; never tonsillitis. Vene-
real disease or exposure denied. Habits regular; no excesses in alcohol, tobacco,
or food. .

* Word has been received of the patient's death in Feb., 1918. The child her-
self was faithful and contented, but the parents concluded to try an independent
experiment to "build her up." The child was kept in ignorance of the glycosuria
which quickly followed the increased diet, and the fatal outcome was due solely
to this foUy of the parents.

286 CHAPTER III

Present Illness. — 8 years ago patient began to feel rather poorly, also had
serious trouble with his teeth. Numerous teeth had to be extracted, and he de-
veloped an infection of the mandible, some of which sloughed away. His physi-
cian diagnosed diabetes. The carbohydrate in his diet was diminished but
other foods were not restricted. Since that time he has had occasional attacks of
polydipsia, otherwise no diabetic symptoms, except more or less continuous trouble
with his teeth. Some recent worries apparently made the condition worse, but
he remained in fair health and able to work until Jan. 3, 1915, when his neck
began to pain and swell. He was immediately taken in charge by an eminent
New York surgeon who had been an old-time friend. The pain required mor-
phine, and the fever and progressive advance of the border of infection were so
threatening that the surgeon contemplated complete excision of the infected
area and brought the patient to this Institute with the intention of operating the
same or the following day.

Physical Examination.— Height 169 cm. Weight 59.6 kg. A well developed,
fairly well nourished man, with fever, flushed face, unduly bright eyes, and ap-
pearance of prostration. Numerous teeth missing; much caries and pyorrhea.
On the left side of the neck behind, there is a very large carbuncle with its
apex about midway between the postaural line and the posterior median line,
and with marked redness and induration extending past the posterior median
line behind and to the internal border of the sternocleidomastoid in front. The
whole area is intensely tender and movements of the neck are prevented. Physi-
cal examination otherwise negative.

Treatment. — Fever was continuous, but the highest temperature was 102.5.°
Morphine was required to control pain, particularly at night. There was a
heavy ferric chloride reaction, and the urine on the 1st day contained 36.4 gm.
sugar, on the 2nd day 32.4 gm. The diet on this day Qan. 16) was 87 gm. pro-
tein, 11 gm. carbohydrate, and 1400 calories. The general condition was criti-
cal, and the surgeon felt impelled to operate by the approach of the infection to
the plane of the great vessels of the neck; but in view of the acidosis and nega-
tive carbohydrate balance it was advised that operation be postponed for at least
a day or two until the influence of fasting could be brought to bear. Accordingly,
fasting was begun on Jan. 17, with as much whisky as could be comfortably
taken for the sake of keeping up strength. The quantity of alcohol thus taken
was from 700 down to 500 calories daily. After 1 day of fasting the glycosuria
had fallen to 9.75 gm. and the general condition was at least no worse. The
glycosuria continued to diminish on the following days and was absent on the
4th day of fasting. Meanwhile the general condition improved, pain dimin-
ished, the apex of the carbuncle began to discharge pus, and the night of Jan. 21
was the first on which morphine was not required. 2 days of complete freedom
from glycosuria were allowed to pass before the addition, on Jan. 22, of 9 gm.
carbohydrate in the form of tomatoes, celery, and lettuce to the daily allowance
of whisky. On Jan. 23 this was raised to approximately 20 gm., and on Jan.

■ CASE RECORDS 287

24 to 30 gm. On account of traces of glycosuria it was diminished on the follow-
ing days to 6 gm., and following that both whisky and carbohydrate were in-
creased, so that from Feb. 7 to 27 the diet was usually just below 40 gm. carbo-
hydrate and 100 gm. alcohol daily. The fever had gradually fallen, but the
temperature remained between 99° and 100°F. until Jan. 31, after which it was
normal. The core of the carbuncle was extruded on Jan. 30, but full healing of
the large local inflammation was not complete until Mar. 1. With continuance
of the diet mentioned, the traces of glycosuria became less frequent as the in-
fection cleared up, so that the allowance of 40 gm. carbohydrate and 100 gm.
alcohol was fully tolerated.

Beginning Mar. 1 a diet was gradually built up, at first containing only some
20 gm. protein and SOO non-alcohol calories, but rising by Apr. 8 to 115 gm. pro-
tein, 40 gm. carbohydrate, and 2650 calories. Whisky was then discontinued
and, except for the fast-day of Apr. 11, was not used again even on fast-days. A
regular diet was planned consisting of 90 to 100 gm. protein, 25 gm. carbohy-
drate, and 2000 to 2200 calories; this was in the neighborhood of 2 gm. protein
and 40 calories per kg. of body weight, reduced one-seventh by the weekly fast-
day, so that the actual average was nearly 1.5 gm. protein and 35 calories per kg.

After the initial critical infection was overcome, the patient had been left weak
and debilitated, complaining of pains in the legs and other parts of the body.
The blood pressure on Feb. 11 was down to 90 systolic, 70 diastolic. He gained
strength while losing weight, and still more as his weight was slightly built up.
He was encouraged to begin exercise as soon as strength permitted, and this
was increased until at the time of discharge he was taking long walks daily. He
had not only regained the condition present before the carbuncle, but had reached
a state of health better than at any time during the previous years of diabetes.
He was discharged to undertake his regular work.

Acidosis. — ^This was measured at the outset only by the ammonia excretion,
which was modified by alkali dosage. As a measure of precaution against the
acidosis to be feared with an infection, sodium bicarbonate was given beginning
Jan. 16. On this day the total taken was 15 gm., on the next day 40 gm., and
this daily quantity was continued with scarcely any change until Feb. 3, when it
was diminished to 10 gm. On Feb. 7 it was increased to 20 gm., on Feb. 10 to
30 gm., and on Feb. 19 to 40 gm. This was continued until Feb. 23, when it
was abruptly stopped. On Mar. 3, 10 gm. soda were begun and continued to
Mar. 13, after which soda was permanently discontinued.

The chart gives the impression that the patient had been threatened with a
serious acidosis. The low ammonia value shown on the day of admission repre-
sents only part of a day. The excretion of approximately 1.4 to 1.6 gm. ammonia
nitrogen Jan. 17 to 21 occurred in spite of the considerable alkali dosage men-
tioned. The carbon dioxide capacity of the plasma was kept within normal
limits during this alkali treatment, at least after Jan. 29. High normal values
were present on Feb. 18 to 22 with 30 to 40 gm. bicarbonate daily, and the am-

288 CHAPTER III .

monia nitrogen was also down to the low figure of 0.25 to 0.35 gm. Promptly
with the omission of soda on Feb. 23 the plasma bicarbonate fell sharply and the
ammonia began a corresponding steep rise. On Mar. 2 the CO2 capacity touched
its lowest point of 43 .6 vol. per cent, and the ammonia N on the same day had risen
to 2.8 gm. The use of 10 gm. sodium bicarbonate daily, beginning Mar. 3, pro-
duced a rather prompt rise of the plasma bicarbonate. The ammonia fell only
shghtly, then rose to an actually higher level on Mar. 8. The increase of pro-
tein in the diet was presumably one factor. By Mar. 13, however, the ammonia
nitrogen was down to 1 .68 gm. By this time the strength of the acidosis seems to
have been broken. On Mar. 24, without alkali, the ammonia was slightly lower
(1.4 gm. N). The next day it fell sharply to 0.56 gm., and almost simultaneously
the ferric chloride reactions became light for the first time. The ammonia was
equally low on the fast-day of Apr. 4. With the high diets of Apr. 5, 6, and 7
it was higher, and fell again on the fast-day of Apr. 11. After that it varied
between 0.4 and 1.25 gm. N. Likewise, following the discontinuance of alkali
on Mar. 13, the plasma CO2 capacity remained little changed until Mar. 19^
The tests on Mar. 24 and 30 showed it falling rapidly, but it stopped at 44.2 per
cent, and then rose spontaneously within normal limits without the aid of alkali.

The impression is given that alkali was a useful temporary aid in this case.
The milder grades of acidosis may be ignored, and the severer ones also can fre-
quently be treated successfully without alkaU, but when there is a tendency to
serious acidosis overtaxing the defenses of the alkaUne reserve of the body, both
comfort and safety are apparently served by the use of sufficient quantities of
alkali, which are discontinued when proper treatment has overcome the essential
condition imderlying the acidosis.

The ferric chloride reaction was heavy at admission and became intense fol-
lowing the use of soda. It proved very persistent, in conformity with the other
manifestations of the tendency to acidosis. The condition being satisfactory in
other respects, this reaction was left to wear itself out with time and improve-
ment of tolerance. As stated, it became negative some months after discharge,
and has not reappeared.

Blood Sugar. — Analyses were made during the latter part of the hospital period,
and the relatively low values found constituted one feature of the favorable
picture.

Weight and Nutrition. — ^The steep fall in weight, which was intentionally re-
duced from 59.6 kg. on Jan. 16 to 47 kg. on Mar. 4 — a loss of 12.6 kg. in 48 days —
is one of the noticeable features of the treatment. It was necessary first to con-
•trol radically the diabetes which was responsible for the susceptibility to infec-
tion. Second, it was necessary to build up tolerance for carbohydrate and other
foods, in order to save the patient from the persistent acidosis and weakness.
These objects were accomplished by rigorous undernutrition. The patient with
acute infection and fever was subjected to 5 days of fasting with alcohol. After
that, nothing but a little green vegetables was added up to Mar. 1, the idea being

CASE RECORDS 289

to continue undernutrition while combating acidosis by the use of carbohydrate
to the limit of tolerance under the conditions of highest tolerance; viz., exclusion
of other food. Except for these green vegetables, there was complete depriva-
tion of solid food for the 42 days from Jan. 17 to Mar. 1. The fall in weight
was therefore to be expected, and from the urea and ammonia curves it is also
possible to estimate a considerable loss of body nitrogen. It is to be empha-
sized that under these conditions the resistance to infection apparently, and the
general strength certainly, irnproved. Weakness and lowered resistance are to
be regarded as due more to the specific diabetic disorder than to depletion of
food materials, and the policy of trying to strengthen diabetic patients by feeding
in excess of the tolerance is an injurious one.

After the crisis was past, the condition gradually began to assume its proper
proportions as a comparatively mild case of diabetes. In view of the patient's
age and the demonstrated food tolerance, a fairly liberal diet was built up,
sufficient for health and efficient work, and a moderate gain of weight was also
permitted. At discharge, however, the weight was only 50.4 kg.; i.e., 9.2 kg.
below the weight at entrance. The patient has since obeyed the injunction not
to put on much flesh, and is now thin, wiry, and strong.

Subsequent History. — The patient adhered to his diet and remained free from
glycosuria except for a trace on June 18, after ISO gm. strawberries for break-
fast. A moderate ferric chloride reaction was still present on Dec. 27, 1915,
but cleared up not long after that. He later undertook work which made diffi-
cult the accurate weighing of food, and he was therefore allowed to estimate the
quantities from his previous experience. He has since remained free from glyco-
suria, ketonuria, and all symptoms. He feels as well as at any time in his life
and has risen to the position of cashier.

The carbuncle made the diabetes worse, but the mouth condition was seemirigly
the result rather than the cause of the diabetes; for after the therapeutic con-
trol of the diabetes, the patient now with ordinary dental care remains free from
tooth trouble.

Remarks. — ^This was one of the difficult cases of serious infection which may
cause even mild diabetes to turn suddenly severe, incidentally illustrating the
functional as opposed to the organic element in human diabetes. Numerous
fatalities are inevitable with such a combination. The favorable outcome in this
case must undoubtedly be attributed largely to the fact that the carbuncle was
near the point of discharging spontaneously, so that a few days of fasting are
not to be credited with radical cure of the infection. On the other hand, good
evidence is afforded that the resistance was not lowered by fasting, and the be-
lief is that it was raised. Likewise the subsequent treatment by undernutrition
has not made the patient susceptible to infections and other mishaps, but has
on the contrary relieved him of these and all other diabetic complications.

290 CHAPTER III

CASE NO. 28.

Female, age 11 yrs. American; schoolgirl. Admitted Jan. 19, 1915.

Family History.— A paternal granduncle died of tuberculosis some years ago.
No other disease in family. Father, mother, and one brother of patient entirely
weU.

Past History.— Healthy life. Whooping-cough at 5, measles at 6, and mumps
at 10. A strong, active child, Uving imder good hygienic conditions in a small
town in New York. In Aug., 1913, she had fever for 24 hours. Temperature
was as high as 104°, and the physician could make no diagnosis. There were a
few cases of poliomyelitis in the neighborhood about that time. For a short
time afterward, the patient was subject to nervous movements and had pain
in ankles without objective signs of inflammation. Habits always regular. Dis-
position not nervous. She has been on the honor roll at school, but has been
kept from overstudy.

Present Illness. — While visiting in New York City after New Years day this
year, polyuria was noticed, and when this continued several days the patient's
mother suspected diabetes, and the diagnosis was made by her physician. The
nervous movements noted after the previous illness were now increased. A diet
was prescribed excluding most ordinary carbohydrates, but including gluten bread,
toast, and milk.

Physical Examination. — A healthy looking girl, well nourished and rather
large for her age. The face appears nervous, and there are twitching or chorei-
form movements of the head and arms. Teeth in good condition. Tonsils
hypertrophied. Enlargement of epitrochlears but not of other lymph nodes.
Knee and other reflexes exaggerated. Examination otherwise negative.

Treatment.^-The glycosuria of 1.6S per cent present when patient was brought
to the hospital ceased immediately on a carbohydrate-free diet of 600 to 650
calories, but the ferric chloride reaction, which had been negative, developed in
moderate intensity on the second day of this diet. 2 fast-days were then im-
posed Qan. 21 and 22), and the ferric chloride color became intense. Green
vegetables were begun in the usual manner on Jan. 23 and increased until the
limit of tolerance seemed to be reached with 133 gm. carbohydrate on Feb. 1.
Instead of a fast-day on Feb. 2, the vegetables were merely diminished to 36
gm. carbohydrate. Under this program the ferric chloride reaction had become
much paler, the ammonia nitrogen had fallen from 0.85 gm. on Jan. 25 to very
low figures, and the plasma bicarbonate had risen from 47 per cent on Jan. 25
up to the lower normal Umit. Carbohydrate-free diet was begun on Feb. 3 with
two eggs, 20 gm. butter, and 250 gm. thrice cooked vegetables. This diet was
rapidly increased and carbohydrate introduced. On Mar. 1 to 3 the patient
proved able to tolerate 80 to 90 gm. protein, 50 gm. carbohydrate, and 3000
calories, without glycosuria but with persistence of a sUght ferric chloride reac-
tion. She was discharged Mar. 5 on a diet of 72 gm. protein, 30 gm. carbohy-
drate, and 2500 calories (approximately 2.5 gm. protein and 90 calories per kg.).

292 CHAPTER m

lation was actually diminished. Carbohydrate up to 140 gm. was tolerated per-
fectly, then heavy glycosuria occurred. The child was brought to confess that
this was due to stealing bread, and that the difficulties in the preceding months
had been due to the same cause. By Oct. 12 she was taking 75 gm. protem,
30 gm. carbohydrate, and 1500 calories, weighed 86 pounds, and had grown 2i
inches since leaving hospital. On Jan. 10, 1917, the first menstrual period ap-
peared in normal manner, but none has appeared since that time. The re-
port on Jan. 18, 1917, showed that she was taking 80 gm. protein, 24 gm. carbo-
hydrate, and 1625 calories, and weighed 901 pounds.

In Mar., 1917, she went through German measles without glycosuria. There
have been occasional traces of glycosuria, the trouble being partly due to indulgent
management, but these traces are always cleared up immediately and com-
pletely by fasting. The patient feels and appears entirely well and is continuing
normal activities.

Remarks. — The history suggests that this is a case of diabetes resulting from
an acute infection. If so, the damage produced was not transitory. The pa-
tient remains diabetic, and is liable to take an unfavorable turn from some acci-
dental disturbance at almost any time; spontaneous downward progress is not
noted. There is a definite improvement, but not to any extent suggesting a
complete cure. If such improvement can continue the ultimate outcome may be
very favorable. Actual recuperation to this degree, especially on rather high
diets, is unusual, and possibly stands in relation to an exceptional etiology. If
diabetes is caused by a transitory infection, the repair of the damage may some-
times be partial instead of complete. Possibly childhood may actually favor re-
pair under the special conditions. In the absence of complete recovery, there is
no doubt that neglect of diet will entail rapid downward progress. Dietetic
treatment may save in proportion as it is early and effective. If the improve-
ment can continue, the ultimate outcome in this particular patient may be very
favorable. Thus far at any rate, in this case of juvenile diabetes, taken at an
early, fairly mUd stage, it has been possible through 2 J years to obtain improve-
ment rather than downward progress, along with seemingly normal growth and
development.*

CASE NO. 29.

Female, unmarried, age 26 yrs. Finnish; domestic. Admitted Jan. 27, 1915.

Family History. — ^Parents are living; both have heart trouble. One brother is
well. Two sisters died of tuberculosis and three others of unknown causes in
adult life. Family history otherwise negative for tuberculosis, cancer, syphilis,
and diabetes.

Past History. — Healthy life, spent in comfortable circumstances on farm in
Finland up to 3 years ago, since then patient has been employed as domestic

* A relapse has occurred, and the patient has been referred elsewhere for treat-
ment. The experience is a further warning of the pernicious effect of high diets.

CASE RECORDS 293

in the better parts of New York. For the past i months she has been a cook.
No illness remembered, except whooping-cough in childhood. Occasionally-
patient spits a little bright red blood. Diet has been rich in starch but not in
sweets. No excesses or bad .habits.

Present Illness. — ^Just after the recent Christmas holidays the patient first
noticed weakness, weariness, polyphagia, polydipsia, and the loss of IS pounds
weight. A physician immediately diagnosed diabetes.

Physical Examination. — A well appearing, fairly well nourished young woman.
Teeth in good condition. Throat sUghtly congested; tonsils show neither hy-
pertrophy nor exudate. Cervical, epitrochlear, and inguinal lymph nodes not
palpable. Axillary glands are shot-like. General examination negative. Blood
pressure 110-90.

Treatment. — ^The partial urine specimen on the day of admission showed 1.69
per cent, or 7.52 gm. sugar. On the next day (Jan. 28), on a carbohydrate-free
observation diet of 68 gm. protein and 1350 calories there was glycosuria of only
2.1 gm. Anorexia had come on before admission, so this diet was aU the patient
cared to take. On Jan. 29 fasting was begiin^ and on the subsequent days as
much as 100 cc. whisky were allowed; larger quantities could not be taken be-
cause of nausea. The urine immediately became sugar-free, but a weU marked
ferric chloride reaction persisted, partly perhaps because of the use of sodium
bicarbonate. Because of the slightly subnormal CO2 capacity of the plasma
and the seeming tendency to weakness and nausea, 50 gm. sodium bicarbonate
had been given on the first day of fasting (Jan. 29) and 100 gm. on the second
fast-day (Jan. 30). The cUnical condition was not perceptibly altered, and
gave no indication of either benefit or injury. On Jan. 31, after the urine had
been sugar-free over 72 hours, green vegetables were allowed containing 5 gm.
carbohydrate. This quantity was increased up to 100 gm. carbohydrate on
Feb. 4 and 5. This was tolerated without glycosuria. But with the protein-fat
diet of 1200 to 1700 calories (Feb. 8 to 12), traces of glycosuria occurred
with an intake of only 9 gm. carbohydrate.

Owing to the persistence of ferric chloride reactions, another period of alcohol
and green vegetables was given up to Feb. 25. Thereafter only traces of glyco-
suria resulted from very high diets; e.g., 90 gm. protein, 35 gm. carbohydrate,
and 3600 calories on Mar. 8 to 10. The diet was then adjusted so that at dis-
charge on Apr. 21 it consisted of 90 gm. protein, 50 gm. carbohydrate, and nearly
3000 calories (approximately 2 gm. protein and 70 calories per kg.). The weight,
which had been markedly reduced during undernutrition up to Feb. 25, increased
on the higher diets, so that at discharge it was almost at the admission level.

All symptoms had disappeared and the patient felt entirely well. Radio-
graphs and repeated sputum examinations failed to reveal any tuberculosis.

In Apr. the patient received word that her only brother had died of tubercu-
losis. She therefore insisted upon returning to Finland. The bad news and the
preparations for departure brought on no glycosuria. She was given a letter to
a professor in Helsingfors, and was warned to remain free from glycosuria under
all conditions.

294 CHAPTER ni

Remarks. — ^The case is not instructive. Even with allowance for the weekly
fast-days the diet was too high for permanently good results. The patient was
ignorant of the gravity of her condition and it was judged that she would not ad-
here to any serious restrictions, and this became more certain when she decided
to return to Finland. Rather than have her break away from restrictions alto-
gether, it seemed advisable to plan a diet adequate to permit her to work and
feel well for the present and not attempt a more ideal result. Nothing has been
heard of the patient since discharge.

CASE NO. 30.

Female, married, age 45 yrs. American; housewife. Admitted Jan. 30,
1915.

Family History.— FsLthei is living, aged 72. Mother died at 47, following
operation for fibroids. One sister died at 35, following operation for an old
traumatic hip; three sisters are well. No diabetes or other special diseases
known in family. Patient has been married 25 years and has had seven chil-
dren; three are alive and well, the others died in infancy when the mother was in
bad condition or suffering from grippe or typhoid.

Past History. — Usual childhood diseases (history indefinite). Typhoid fever
25 years ago. Grippe at several times; no sore throat. Appendicitis 8 years ago;
operation. 7 years ago curettage for menorrhagia. Operation for mastoiditis 6
years ago. For some years past the patient has been nervous and suffered from
nervous indigestion. Feces have also been pale, but never showed blood. Habits
have been regular, diet simple; no excesses.

Present Illness. — First symptom was pruritus vulvae 7 months before admission,
followed by marked polyphagia, polydipsia, and poljTiria. She sought no treat-
ment for 4 months, then was placed on a diet, carbohydrate-free except for green
vegetables and one sUce of toast. She has lost 35 pounds weight. During 2
days prior to admission to hospital her physician had placed her on absolute
fasting with whisky and sodium bicarbonate.

Physical Examination. — ^Woman without dyspnea or acute symptoms, moder-
ately weak. Body shows evidence of considerable loss of weight, but still carries
fair quantity of fat. Eyes react normally and ophthalmoscopic examination is
negative. Teeth are in good repair. Throat congested; tonsils free from exu-
date or hypertrophy. Cervical and inguinal glands not palpable, axillaries and
epitrochlears slightly enlarged. Knee jerks obtained only on reinforcement, and
then sluggishly. Achilles jerks present. Blood pressure 110 systolic, 85 diastolic.
General examination negative.

Treatment. — Patient seemed in fair condition and in no danger when admitted.
Only shght glycosuria was present, and only a moderate ferric chloride reaction.
She was admitted in the afternoon and received supper consisting of soup, 100 gm.
steak, and 100 gm. raw and 100 gm. thrice cooked vegetables. She was men-
struating, and had slight diarrhea. A phenolphthalein tablet and 15 gm. mag-

CASE RECORDS 295

nesium sulfate produced small liquid or soft movements which continued undSr
small doses of cascara on the following days. On the first full day in hospital
(Jan. 31) the diet consisted of 81 gm. protein, 5 gm. carbohydrate, and 1650 cal-
ories. Glycosuria was entirely absent, the ferric chloride reaction still only
moderate, and the condition apparently satisfactory. The next day, Feb. 1,
the diet consisted of SO gm. protein, 12 gm. carbohydrate, and 1250 calories. The
patient showed slight nausea. On Feb. 2, the diet consisted of coffee, soup, one
egg, and 600 cc. milk, representing 27 gm. protein, 30 gm. carbohydrate, and 500
calories. Nausea had increased, and on this day the patient vomited once a
little undigested food. She said she had often had such attacks with her indi-
gestion in the past. With small doses of chloretoUe, also a Seidlitz powder fol-
lowed by a saline enema which removed considerable feces, the nausea seemed
greatly diminished. Meanwhile a trace of glycosuria had appeared from the
carbohydrate, and the ferric chloride reaction had become intense, but the highest
ammonia nitrogen output (Feb. 2) was 1.9 gm. On Feb. 3, the diet was limited
to 300 cc. clear soup, 300 cc. milk, and 90 cc. whisky. The patient also received
3 cc. aromatic cascara, 30 cc. Pluto water, and 10 gm. sodium bicarbonate. On
Feb. 4, as glycosuria and ketonuria were well marked and the patient was slightly
nauseated, a fast-day was given, the entire intake being 150 cc. coffee, 130 cc.
whisky, 15 gm. sodium bicarbonate, 3 cc. aromatic cascara, and 30 cc. Pluto
water. Though the urine remained acid, the glycosuria diminished to a trace,
ammonia fell to 0.87 gm. N, and the CO2 capacity of the plasma, which had been
only 35.8 per cent on Feb. 2, rose to 57.7 vol. per cent on Feb. 4. Feb. 5 was also a
fast-day, the intake being 140 cc. whisky and 15 gm. sodium bicarbonate. The
urine remained acid. In the morning the patient felt well; toward evening she
was slightly dizzy and nauseated. Feb. 6 was also a fast-day with 125 cc. whisky
and 25 gm. sodium bicarbonate. The symptoms were more alarming; the tem-
perature was 99.2°F., the pulse 90, the respiration 20; the pulse was weak, and the
patient complained of dizziness and vomited several times. Two doses of 0.5
gm. chloretone were given for the vomiting, and 2 gm. compound jalap powder
to empty the bowels further, though there had been one or more defecations
every day.

On Feb. 7 only 25 cc. whisky could be taken because of nausea. Vomiting
continued notwithstanding the use of a variety of routine measures, and weakness
was becoming serious. The temperature first was as high as 99.8°, but fell by
the close of the day to 96°. The pulse ranged 100 to 130, the respiration 28 to
44. Caffeine was administered at intervals subcutaneously, and later camphorated
oil. An attempt also was made to feed, and milk, eggs, and beef juice were
given and partly vomited. 1 liter of 4 per cent sodium bicarbonate solution was
successfully given by the rectal drip method. The patient had become very
drowsy, almost unconscious.

On Feb. 8, eggs and beef juice were continued, as also the caffeine and cam-
phorated oil. Levulose was also given in small doses totahng 140 gm.; it was

CASE RECORDS 295

nesium sulfate produced small liquid or soft movements which continued under
small doses of cascara on the following days. On the first full day in hospital
(Jan. 31) the diet consisted of 81 gm. protein, 5 gm. carbohydrate, and 1650 cal-
ories. Glycosuria was entirely absent, the ferric chloride reaction still only
moderate, and the condition apparently satisfactory. The next day, Feb. 1,
the diet consisted of SO gm. protein, 12 gm. carbohydrate, and 1250 calories. The
patient showed slight nausea. On Feb. 2, the diet consisted of coffee, soup, one
egg, and 600 cc. milk, representing 27 gm. protein, 30 gm. carbohydrate, and 500
calories. Nausea had increased, and on this day the patient vomited once a
little undigested food. She said she had often had such attacks with her indi-
gestion in the past. With small doses of chloretotxe, also a Seidlitz powder fol-
lowed by a saline enema which removed considerable feces, the nausea seemed
greatly diminished. Meanwhile a trace of glycosuria had appeared from the
carbohydrate, and the ferric chloride reaction had become intense, but the highest
ammonia nitrogen output (Feb. 2) was 1.9 gm. On Feb. 3, the diet was limited
to 300 cc. clear soup, 300 cc. milk, and 90 cc. whisky. The patient also received
3 cc. aromatic cascara, 30 cc. Pluto water, and 10 gm. sodium bicarbonate. On
Feb. 4, as glycosuria and ketonuria were well marked and the patient was slightly
nauseated, a fast-day was given, the entire intake being 150 cc. coffee, 130 cc.
whisky, 15 gm. sodium bicarbonate, 3 cc. aromatic cascara, and 30 cc. Pluto
water. Though the urine remained acid, the glycosuria diminished to a trace,
ammonia fell to 0.87 gm. N, and the CO2 capacity of the plasma, which had been
only 35.8 per cent on Feb. 2, rose to 57.7 vol. per cent on Feb. 4. Feb. S was also a
fast-day, the intake being 140 cc. whisky and 15 gm. sodium bicarbonate. The
urine remained acid. In the morning the patient felt well; toward evening she
was slightly dizzy and nauseated. Feb. 6 was also a fast-day with 125 cc. whisky
and 25 gm. sodium bicarbonate. The symptoms were more alarming; the tem-
perature was 99.2°F., the pulse 90, the respiration 20; the pulse was weak, and the
patient complained of dizziness and vomited several times. Two doses of 0.5
gm. chloretone were given for the vomiting, and 2 gm. compound jalap powder
to empty the bowels further, though there had been one or more defecations
every day.

On Feb. 7 only 25 cc. whisky could be taken because of nausea. Vomiting
continued notwithstanding the use of a variety of routine measures, and weakness
was becoming serious. The temperature first was as high as 99.8°, but fell by
the close of the day to 96°. The pulse ranged 100 to 130, the respiration 28 to
44. Caffeine was administered at intervals subcutaneously, and later camphorated
oil. An attempt also was made to feed, and milk, eggs, and beef juice were
given and partly vomited. 1 liter of 4 per cent sodium bicarbonate solution was
successfully given by the rectal drip method. The patient had become very
drowsy, almost unconscious.

On Feb. 8, eggs and beef juice were continued, as also the caffeine and cam-
phorated oU. Levulose was also given in small doses totaling 140 gm.; it was

296 CHAPTER m

retained but had no evident effect. At 4 p.m., 700 cc. 4 per cent sodium bicar-
bonate were given intravenously. At 10 p.m. 100 cc. were likewise given. The
temperature had slowly risen, and continued to rise, reaching 101° F. at 7 p.m.
on Feb. 8, 101.8° at 1 a.m. on Feb. 9, and 104° at 5 a.m. The pulse remained
about 140, the respiration 40 to 48. Toward the close the picture was that of
fully developed diabetic coma. Death occurred at 6:45 a.m. on Feb. 9.

Remarks. — ^This was the first case seen at this Institute showing development
of fatal acidosis on fasting, and the treatment was mistaken because the condi-
tion was unexpected. The very rapid loss of weight, from 56.8 kg. on Jan. 31,
down to 52.2 kg. on Feb. 7, is a significant feature apparently present in all such
cases. One error in treatment is the low fluid intake and correspondingly low
output as shown in the graphic chart. Salts should also have been more liberally
suppUed. But the chief lesson for such cases is to break off fasting when the
first warning symptoms appear, and after a period of some days of feeding to
repeat the fast, which then is well borne. Suitable preparatory feeding preceding
the initial fast will doubtless also prevent all or nearly all such mishaps.

CASE NO. 31.

Male, unmarried, age 35 yrs. American; real estate agent. Admitted Feb.
12, 1915.

Family History. — Mother is well except for occasional rheumatism. Father
died of sarcoma at 62. One brother and two sisters are well; two died in in-
fancy. No knowledge of any family disease.

Fast History. — Patient has lived all his life in New York City in good health
and hygienic surroundings. Measles and whooping-cough in childhood. Gonor-
rhea 10 years ago. SyphiUs denied; two Wassermann tests in the past have
been negative. In 1889, after ^exposure to a great blizzard in winter, the patient
suffered from inflammatory rheumatism in the spring. This returned almost
yearly until 1895, when he received treatment by medicine, which ended the
rheumatism permanently but left him with persistent bad digestion. 12 years
ago he had St. Vitus' dance, which was cured in a German sanitariimi b}'- rest
and arsenic. He has sore throats every year. No excesses in food, drink, or
tobacco. Since becoming diabetic he has lost about 35 pounds weight. For
about a week past he has had pain in the great toe of the right foot.

Present Illness. — 3 years ago debility without other sjrmptoms began. The
urine was found to contain 5 per cent sugar. This gradually cleared up on
carbohydrate-free diet with addition of one sUce of bread at each meal. In 1913
he became worse and was placed in a hospital, where 3 green days cleared up gly-
cosuria. Since leaving the hospital he has constantly had 3 to 5 per cent sugar
in the urine. He continued work up to 4 months ago; since then he has been
physically and mentally incapacitated.

Physical Examination. — Sallow color; only moderate emaciation; acetone odor
present. Teeth in good repair. TonsUs and throat normal. Axillary glands

CASE RECORDS 297

palpable, but not cervical, epitrochlear, or inguinal. Arteries are palpably scler-
otic. Blood pressure 90 systolic, 75 diastolic. Knee jerks sluggish; Achilles jerks
active. The great toe of the right foot shows a slight abrasion. The toe is
bluish in color, cold to the touch, and the skin between it and the next toe is
lifted up by exudate. Examination otherwise negative.

Treatment.— There were 2 days of observation diet. On Feb. 13, the first full
day in hospital, this consisted of 84 gm. protein, 6 gm. carbohydrate, and 1830
calories. The glycosuria on this day was 31.3 gm., and the ferric chloride reac-
tion was strong. Fasting was then begun, particularly with a view to the in-
cipient gangrene. Whisky was permitted in quantities up to 500 calories of
alcohol. On Feb. 17, whisky was diminished to 30 cc, and 9 gm. carbohydrate
were added. Glycosuria, which had been absent, returned in traces and con-
tinued for 2 days longer, though the carbohydrate on Feb. 18 was diminished to
4 gm., and on Feb. 19 only whisky and 350 gm. thrice cooked vegetables were
given. These traces of glycosuria were accidental, or else continued undernutri-
tion brought rapid improvement; for beginning Feb. 20, 40 to 50 gm. carbo-
hydrate in the form of green vegetables were given daily without glycosuria,
vmtil Feb. 25. On Feb. 26, the carbohydrate was diminished to 10 gm. The
whisky was now 170 cc. Glycosuria ceased, but reappeared Mar. 3 on a diet
of 70 gm. protein and 1700 calories without carbohydrate. It became heavier
as the calories were increased to 2300, stopped with the fast-day of Mar. 7, re-
appeared with the carbohydrate-free diet of 2300 calories on Mar. 8, and ceased
when the diet was cut down to 1200 calories Mar. 9 to 11. There were no
vegetables of any kind in these later diets, so the glycosuria was evidently due
to the protein-fat intake. Thrice cooked vegetables were then added and were
at first tolerated, but glycosuria reappeared on Mar. 13, 14, and 15, on diets lower
in protein and calories than those formerly assimilated. Though the vegetables
on these days consisted only of 150 gm. string beans and 100 gm. celery, both
thrice boiled, the glycosuria was evidently due to this trifle of carbohydrate.
This very low tolerance improved with continued undernutrition and the dim-
inution of other elements in the diet. Thus, beginning Mar. 17, the same
thrice boiled vegetables were tolerated, the protein now being 30 gm. and the
total calories 400. This diet was gradually built up and on Apr. 3 a trace of
glycosuria appeared with 75 gm. protein, 200 gm. thrice boUed vegetables (string
beans and asparagus), and 1700 calories. This stopped on the fast-day of Apr.
4; and on Apr. 5, 5 gm. carbohydrate in the form of asparagus, celery, and lettuce,
without other food, were tolerated without glycosuria. Beginning Apr. 6 the
protein was diminished to 40 gm. and the calories to 1400. With this reduction
in protein, not only did the same quantity of thrice cooked vegetables cause no
glycosuria, but also on Apr. 9 and 10 the addition of 10 gm. carbohydrate was tol-
erated. The attempt during the ensuing week (Apr. 12 to 17) to raise the carbo-
hydrate to 20 to 30 gm. and the calories to 1800 resulted in slight glycosuria.
The tendency to glycosuria gradually diminished, and by July 7 the patient had

298 CHAPTER m

become able to tolerate 80 gm. protein, 25 gm. carbohydrate, and 2150 calories
(over 1.5 gm. protein and 40 calories per kg. for a weight of SO kg., but dimin-
ished one-seventh by the weekly fast-days). He was dismissed on this diet in
good condition.

Acidosis. — This was never acutely threatening. The ferric chloride reaction
was fairly persistent. It cleared up with the undernutrition at the close of Mar.,
and returned with the higher diets in Apr., even though carbohydrate was soon
added to these diets. Then, without special change in the diet, the ferric chloride
reaction gradually disappeared and was absent at discharge. 20 gm. sodium bi-
carbonate were given daily Feb. IS to 22. On Feb. 23, it was diminished to 5
gm., and then stopped. The carbon dioxide capacity of the plasma, as far as
observed after Mar. 18, was within or near normal Umits, and was high at
discharge.

Blood Sugar. — ^This fluctuated, but hyperglycemia was the rule. The last
analysis on June 24 still showed 0.165 per cent. It is evident that hyperglycemia
did not prevent continued improvement in tolerance and sjonptoms. Neverthe-
less, this hjrperglycemia is an unfavorable feature. It could doubtless have been
brought lower, but the patient was unintelligent and untrustworthy. For this
reason an ideal result was not considered possible in his case, and a fairly satis-
fying diet was therefore permitted, with some hope that improvement might stiU
be possible, if he remained continuously free from glycosuria.

Weight and Nutrition. — The rise of 5 kg. in weight from Feb. 15 to 23 was
due to edema resulting from the sodium bicarbonate. The weight fell rapidly on
stopping the bicarbonate. Beginning May 31 there was another onset of edema
independent of bicarbonate or other known cause. Albumin and casts were
absent from the urine. The entire gain in weight from May 31 to June 16 was 6
kg. That this was wholly due to fluid retention, apparently from renal cause,
is shown by the prompt fall following June 16, when salt-free diet was instituted.
The entire period in hospital represented undernutrition such that the weight was
diminished by 4 kg. There was clinical benefit instead of injury. Under the
fasting and subsequent treatment the threatened gangrene cleared up smoothly.
Strength was regained, the appearance and color improved, and at discharge the
patient was able to resume his work, in contrast to the state of incapacity at the
time of admission with higher weight and active diabetes present.

Subsequent History. — ^The patient followed diet and showed normal urine for
several months. In Aug. he passed through a severe bronchitis without show-
ing sugar. Toward Oct. he had much business worry, and analysis showed 0.204
per cent sugar in the whole blood and 0.278 per cent in the plasma (probably
more dietetic than psychic in origin, however). The patient rejected the advice
to return to the hospital at this time because of business emergencies which he
must meet. He again reported at the hospital on Nov. 29. Meantime he had
been traveling through other states under conditions which prevented following
diet. The blood sugar was 0.227 per cent, plasma sugar 0.244 per cent. He was

CASE EECOBDS 299

instructed as to becoming sugar-free at home, and on Dec. 5 reported that glyco-
suria had stopped with 1 day of fasting and had remained absent on his regular
diet. The urine on this date was normal, the blood sugar 0.208 per cent,^ the
plasma sugar 0.2S0 per cent. On Dec. 12 a trace of glycosuria appeared, and
the patient therefore fasted on Dec. 13. The urine was normal, the blood sugar
0.178 per cent, the plasma sugar 0.213 per cent. The patient was continually
inclined to carelessness, but felt worse when showing sugar and therefore made
some attempts at following diet. On Dec. 28 he returned to the hospital.

Second Admission. — ^The urine showed slight sugar and ferric chloride reac-
tions. On the observation diet of Dec. 29, comprising 77 gm. protein, 15 gm.
carbohydrate, and 2000 calories, a trace of glycosuria persisted in the early hours
but cleared up before the close of the day. A fast-day was nevertheless imposed
on Dec. 30, followed by a routine carbohydrate test, which fixed the tolerance at
70 gm. carbohydrate. On the subsequent diets entirely unaccountable traces of
glycosuria occurred, and the patient finally proved to be repeatedly violating
diet. On account of his persistent carelessness and disobedience, he was dis-
missed and was referred to a local speciahst, with the idea that he might appre-
ciate treatment more if he had to pay for it.

Remarks. — On the fast-day of Dec. 30 the blood sugar was 0.111 per cent and
the plasma sugar 0.122 per cent. It is seen that the body weight at the second
admission was identical with that at the former discharge. Notwithstanding
repeated indiscretions in carbohydrate, the patient had kept down his total diet
approximately as directed, and the tendency to a lowering of the hyperglycemia,
as hoped for at the previous discharge, had actually shown itself. The case had
been characterized by very low tolerance in the initial period of the first admission,
but, in consequence of the undernutrition then imposed, had become easy to man-
age. The only difficulty was the light-mindedness of the patient. He was dis-
charged in favorable clinical condition, with prognosis governed by behavior.

CASE NO. 32.

Female, married, age 21 yrs. Russian Jew; housewife. Admitted Feb. 18,
1915.

Family History. — Father died when patient was an infant. Mother well at
51. One brother and one sister well. No heritable disease known.

Past History. — Considerable sickness in infancy. Diphtheria complicated by
measles at 2i years. Pneumonia at 3 years. Healthy life since then. Habits
regular. Diet largely carbohydrate, but no sugar. Married 3 years, has a
healthy 2 year old child. The only recent illness was a 2 day attack of tonsil-
litis 2 years ago.

Present Illness.— Last June began polyphagia, polydipsia, polyuria, weakness,
headache, and pains in legs. Recently pruritus vulvae. Menstruation stopped
last Oct. Patient supposed all the symptoms due to pregnancy, and was sur-
prised when a physician found pregnancy absent and diagnosed diabetes. She
was sent to this hospital for impending coma.

300 CHAPTER ni

Physical Examination. — Height 168.5 cm. A well developed and nourished
young woman, with flushed face and drowsy expression. Dyspnea is present;
respiration about 30 per minute. Teeth in fair condition; some pyorrhea. Ton-
sils moderately hypertropMed; the left axillary and epitrochlear glands pal-
pable; cervical and inguinal not palpable. Knee jerks not obtainable; Achilles
jerks present. Blood pressure 100 systolic, 65 diastolic. Faint albuminuria.

Treatment. — Because of the imminent danger of coma, fasting was begun im-
mediately, with some 400 to 600 calories of whisky daily. Th^ patient was con-
scious though sleepy, and not nauseated. On Feb. 18 she received 10 gm.
sodium bicarbonate and 2 gm. compound jalap powder; 30 gm. sodium bicarbon-
ate on Feb. 20 and 21,10 gm. on Feb. 22. She was thirsty, and was able to drink
as much as 3 liters of water daily, but the main reliance was placed on fasting.
Both the glycosuria and the clinical symptoms rapidly cleared up. The urine
became neutral on Feb. 21. Glycosuria was absent on Feb. 23, but the first food
was allowed on Feb. 26. This consisted only of 12 gm. carbohydrate in the form
of green vegetables. By Mar. 6 it had been increased to 50 gm. carbohydrate
without glycosuria. The whisky meanwhile was continued at 500 calories daily.
It might have been well to have pushed the carbohydrate to the point of glycosuria,
with a view to clearing up the remaining slight ferric chloride reaction. But
after the fast-day with whisky on Mar. 7, protein-fat diet was begun. On Mar.
10 whisky was permanently stopped. The diet was gradually built up to 118
gm. protein, 25 to 27 gm. carbohydrate, and 2600 to 2800 calories (approximately

2.4 gm. protein and 52 to 56 calories per kg. on 50 kg. weight, reduced one-seventh
by the weekly fast-days), with only transient traces of glycosuria. She was
dismissed Apr. 7 on a diet of 85 gm. protein, 20 gm. carbohydrate, and 2500 cal-
ories (1.7 gm. protein and 50 calories per kg. reduced by weekly fast-days to

1.5 gm. protein and 43 calories average). This was weU below what she had
seemed able to tolerate. At discharge she was to all appearances entirely healthy.

Acidosis. — ^The carbon dioxide capacity of the plasma was only 26.4 vol. per
cent at admission. Fasting was evidently the most important factor in raising it,
for on Feb. 19, after only 10 gm. sodium bicarbonate, it had risen to 38.5 per
cent. Under the larger doses of bicarbonate it rose still more rapidly to the
high normal figure of 64.6 per cent on Feb. 22. This was an artificial elevation
resulting from the alkali dosage, for with discontinuance of alkali the COa ca-
pacity fell steeply to 45 per cent on Feb. 25. Under the influence of the small
quantities of carbohydrate it rose spontaneously within normal limits, reaching
62.2 per cent on Mar. 4, without the aid of alkali. It fell on the fast-day of Mar.
7, alcohol alone being apparently unable to hold it up. It continued to fall, on
addition of protein and fat, down to 46.5 per cent on Mar. 10. The steep rise to
56 per cent on Mar. ll and 60 per cent on Mar. 12 is perhaps explainable by the
introduction of 75 gm. protein in the diet. From this time the curve tends to
run near or slightly below the lower normal limit, and was barely at this limit
at discharge. The ferric chloride reaction was intense at the outset, diminished

CASE RECORDS 301

rapidly during the fast, and was down to traces during the ensuing carbohydrate
period. The later diet being a high one, this reaction did not become perma-
nently negative in hospital. Notwithstanding the use of alkali, the ammonia
nitrogen on Feb. 19 was up to 3.54 gm. It fell as steeply as the plasma bicar-
bonate rose. Its general course was still downward after discontinuance of
alkali, but with the beginning of protein-fat diet, as the CO2 capacity fell, the
ammonia again rose, up to 1.9 gm. N on Mar. 11, with a fall thereafter, perhaps
partly because of introduction of carbohydrate, perhaps partly because of the
improved condition. No clinical symptoms were associated with the persistent
traces of ferric chloride reaction and chronically low CO2, and the use of alkali
was not indicated.

Blood, Sugar. — ^This was down to 0.128 per cent on the morning of Mar. 22,
following the preceding fast-day. On Apr. 3, at the close of a week of high diet,
it was up to 0.192 per cent. Following the fast-day of Apr. 4, the blood sugar
on the morning of Apr. 5 was found to have returned promptly to the normal
level of 0.117 per cent. At discharge on Apr. 7 it was 0.133 per cent. It could
have been kept rigidly within normal limits, but a gradual fall was hoped for
with continued improvement under suitable diet.

Weight and Nutrition. — ^The initial fall in weight during fasting was moderate,
amounting to 2 kg. in 8 days. The bicarbonate did not produce edema, but
beginning Feb. 26 the green vegetables produced a definite water retention, as
often happens, so that the weight on Mar. 2, after practically continuous fasting,
was 1 kg. higher than at admission. This slight but visible edema cleared up
spontaneously and did not return. It wUl be noted that the initial fasting
treatment, which cleared up the impending coma, consisted in 18 days of total
abstinence from food, except the moderate quantities of alcohol and trifle of
green vegetables. The weight fell from 53.2 kg. on Feb. 18 to 49 kg. on Mar.
9, a loss of 4.2 kg. Later with higher diets it tended to rise slightly, but was
only 50 kg. at discharge; i.e., 2.3 kg. less than at admission. It was hoped that
the case was mild enough to permit a moderate gain in weight, and as the patient
had to work, a liberal diet was allowed as described.

Subsequent History. — ^This patient, though poor and uneducated, adhered
strictly to dietary instructions. The urine was continuously free from sugar
and the ferric chloride reaction had disappeared, therefore lO gm. carbohydrate
were added to the diet on May 26. On June 4, the blood sugar was 0.105 per
cent; on June 11, 0.122 per cent in the whole blood, 0.143 per cent in the plasma.
The weight had risen to 56.3 kg. By Oct. 12, it had risen to 62.3 kg. The blood
sugar then was 0.130 per cent and the CO2 capacity of the plasma 66.2 vol. per
cent. The diet was then increased by 200 cc. milk, as the patient reported her-
self not yet quite up to full workiiig strength. On Nov. 3, the sugar in the
blood was 0.149 per cent, in the plasma 0.175 per cent, and the CO2 capacity was
56.3 per cent.

On Nov. 22, the sugar in the blood was 0.130 per cent, in the plasma 0.143

302 CHAPTER III

per cent, and CO2 capacity 42.5 per cent. The first trace of sugar was reported
in the urine.

On Dec. 6, the patient reported having had cold and cough for 10 days. The
urine remained normal, and she probably ate less than usual, for the sugar was
found to be 0.100 per cent in the blood, 0.105 per cent in the plasma; the CO2
capacity 65.5 per cent.

On Dec. 23, the patient reported at the hospital with fever of 100°, com-
plaining of pains in joints and chest. She continued to feel badly and lost a
few pounds in weight. The urine remained normal. Her menstruation, which
had returned in the autumn, had again ceased.

On Dec. 27, she was readmitted because of her cold or grippe, though diabetic
symptoms were absent.

Second Admission. — Coryza was present, but the general appearance was good.
Temperature was never above 99.8°F. The body weight was now 58.3 kg., as
compared with 53.2 kg. at the first admission. Glycosuria was present Dec.
29 to 31, on a diet of 90 gm. protein, 50 gm. carbohydrate, and 2075 calories (1.54
gm. protein and 35.6 calories per kg.). The low blood sugars recorded mornings
before breakfast show the absence of any continuous hyperglycemia. The am-
monia nitrogen was 0.73 gm., and the total acidity (Henderson) 205. A carbo-
hydrate tolerance test was instituted in the usual manner, beginning with a fast-
day on Jan. 2. The increase in carbohydrate was made more rapidly than usual
because of the high tolerance, which was found to be approximately 180 gm.
carbohydrate. The patient was discharged on Jan. 16, 1916, weighing 57.8 kg.,
with a prescribed diet of 100 gm. protein, 50 gm. carbohydrate, and 2000 calories
(1.7 gm. protein and 35 calories per kg., reduced one-seventh by the weekly
fast-days). She was advised this time to take as much open air exercise as pos-
sible in order to buUd up her strength and relieve her chronic neurasthenia. The
blood sugar had now come down to normal, so that all tests were normal in all
respects, and the physical condition was entirely favorable.

Subsequent History. — The patient remained free from glycosuria and acidosis,
notwithstanding an attack of tonsillitis in Mar. Normal menstruation returned
in Apr. In July she again had fever and a grippe-Uke iUness.

Third Admiss